AIRCRAFT ACCIDENT DIGEST

No. 7

Prepared by the Secretariat and published

by authority of the Secretary General

INTERNATlONAL
C I V I L AVIATION
O R G A N I Z A T I O N
MONTREAL CANADA
 T h i s Publication is i s s u e d i n English, F r e n c h and Spanish.

Published i n Montreal, Canada, by the

International C i v i l Aviation Orpanization.
C o r r e s p o n d e n c e concerning publications
should be a d d r e s s e d t o the Secretarw G e n e r a l
of ICAO, International Aviation Building,
1080 University S t r e e t , Montreal, Canada.

O r d e r s for ICAO publications should b e sent, on payment:

In Canadian c u r r e n c y ($1, t o In Sterling o r I r i s h c u r r e n c y (s/d), t o

S e c r e t a r y General, ICAO, H e r Majesty's Stationery Office,

International Aviation Building, P.O. Box 569,
1080 University S t r e e t , London, S. E. 1,
Montreal, Canada, England.
(Cable a d d r e s s : ICAO MONTREAL) (Cable a d d r e s s :
WHOLECORN, SEDIST, L0NLK)N)

In F r e n c h c u r r e n c y (fr), t o 1to ,
1CAO Representative, ICAO Representative,
r o e a n and African Office, Middle E a s t Office,
:>isP , avenue d'Idna, Wadie Saad Building,
P a r i s (16e). F r a n c e . S h a r i a Salah e l Dine,
( c a b l e 'add;ess: ICAOREP PARIS) Zamalek, C a i r o , ~ & t .
(Cable address: IC AOREP CAIRO)

In P e r u v i a n c u r r e n c y (soles), t o In T h a i c u r r e n c y (bahts)! t o

ICAO Representative, ICAO Representative,

South A m e r i c a n Office, F a r E a s t and P a c i f i c Office,
Apartado 680, S a l a Santitham, Rajadamnoen Ave.,
Lima, Per6. Bangkok, Thailand.
(Cable a d d r e s s : ICAOREP LIMA) (Cable a d d r e s s : ICAOREP BANGKOK)

In Australian c u r r e n c y (s/d), t o In Indian c u r r e n c y (Rs. ), t o

-
Robertson a n d Mullens, Oxford Book and Stationery Company,
107 Elizabeth S t r e e t , Scindia House,
Melbourne, C. 1, A u s t r a l i a . New Delhi, India.

In Argentine c u r r e n c y (pesos), t a

E d i t o r i a l Sudarnericana S .A.,
C a l l e Alsina 500,
Buenos A i r e s , Argentina.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 1

TABLEOFCONTENTS
Page

F O R E W O R D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

COMMENTS ON ACCIDENT CLASSIFICATION TABLES AND SUMMARY O F REPORTED

ACCIDENT CAUSES - 1955 ................................. 9

CLASSIFICATION TABLES "A" AND "B" . . . . . . . . . . . . . . . . . . . . . . . . . . 11

PART I. - SUMMARIES O F AIRCRAFT ACCIDENT REPORTS . . . . . . . . . . . . . . . 15

1. - Northwest Airlines, Douglas DC-4 a i r c r a f t , c r a s h e d a t Sandspit, B r i t i s h

Columbia, Canada, on 19 J a n u a r y 1952. Civil Aeronautics B o a r d (USA)
Accident Investigation R e p o r t No. SA-255, F i l e No. 1-0017 .......... 15

2. - KLM Royal Dutch A i r l i n e s , Douglas DC-6B a i r c r a f t , PH-DFO, c r a s h e d into

the North S e a , 10 nautical m i l e s w e s t of Egmond, T h e Netherlands, on
23 August 1954. R e p o r t of Accident Investigation Bureau, D e p a r t m e n t of
Civil Aviation of T h e Netherlands, adopted 14 November 1955 ......... 17

3. - KLM Royal Dutch A i r l i n e s , Lockheed Super Constellation, c r a s h e d i n the

e s t u a r y of the River Shannon, I r e l a n d , on 5 S e p t e m b e r 1954. D e p a r t m e n t
of Industry and C o m m e r c e , I r e l a n d , Accident Investigation Report, r e l e a s e d
31 J a n u a r y 1955. ................................. 20

4. - National A i r l i n e s , Inc. , Lockheed L o d e s t a r , P i n e l l a s County International

A i r p o r t , St. P e t e r s b u r g , F l o r i d a , 10 J a n u a r y 1955. Civil Aeronautics
B o a r d (USA) Accident Investigation R e p o r t No. SA-300, F i l e No. 1-0001,
r e l e a s e d 17 June 1955 .............................. 35

5. - T r a n s - W o r l d A i r l i n e s , I n c . , Martin 202-A and Castleton, Inc., Douglas DC-3C,

collided n e a r G r e a t e r Cincinnati A i r p o r t , Ohio, on 12 J a n u a r y 1955. Civil
Aeronautics B o a r d (USA) Accident Investigation Report No. 1-0014, r e l e a s e d
8 July 1955 .................................... 39

6. - B r i t i s h European Airways, Viscount a i r c r a f t , G-AMOK, c r a s h e d into a

b a r r i e r while taking off f r o m London A i r p o r t , England, on 16 January 1955.
Report dated 24 August 1955 r e l e a s e d by M i n i s t r y of T r a n s p o r t and Civil
Aviation (U. K. ) ................................... 44

7, - United Air L i n e s , I n c . , Convair 340, m a d e a wheels-up e m e r g e n c y landing

southeast of D e x t e r , Iowa, on 19 J a n u a r y 1955, Civil Aeronautics B o a r d
(USA) Accident Investigation Report No. SA-302, F i l e No. 1-0026, r e l e a s e d
7 S e p t e m b e r 1955................................. 58

8. - Indian A i r l i n e s Corporation, Douglas DC-3, VT-COZ a i r c r a f t , c r a s h e d n e a r

Gauhati Airport. India, on 21 J a n u a r y 1955, R e p o r t d a t e d 23 M a r c h 1955
r e l e a s e d by Ministry of Communications, Government of India. ........ 61

9. - Indian A i r l i n e s Corporation, Douglas DC-3, VT-CVBI a i r c r a f t , c r a s h e d n e a r

Nagpur A i r p o r t , India, on 2 F e b r u a r y 1955. R e p o r t dated 1 M a r c h 1955
r e l e a s e d by Ministry of Communications, Government of India. ........ 65

10. - SABENA (Soci6tC Anonyme Belge d1Exploitation de l a Navigation Aerienne),

DC-6 a i r c r a f t , 0 0 - S D B , c r a s h e d a t Costone delllAcquasanta, Reatini
Mountains, on 13 F e b r u a r y 1955. Report by M i n i s t e r i o Difesa Aeronautica,
Italy... ..................................... 68
2 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5

Page

11. - T r a n s World A i r l i n e s . Inc.. M a r t i n 404 a i r c r a f t , c r a s h e d on Sandia

Mountain, n e a r Albuquerque, New Mexico, on 19 F e b r u a r y 1955. Civil
Aeronautics B o a r d (USA) Accident Investigation R e p o r t No. SA-303,
F i l e No. 1-0063, r e l e a s e d 12 October 1955 ................. 74

12. - De Havilland 104 llDove", LQ-XWW, c r a s h e d on take-off a t F o r m o s a

A i r p o r t , T e r r i t o r y of F o r m o s a , Argentina, on 26 F e b r u a r y 1955.
Argentine A c c i d e n t Investigation R e p o r t No. 465, r e l e a s e d 30 August
1955 ..................................... 77

13. - C e n t r a l African A i r w a y s , Viking 1B VP-YEX, c r a s h e d a t B e l v e d e r e

A i r p o r t , S a l i s b u r y , Southern Rhodesia, on 17 M a r c h 1955. R e p o r t of

of Rhodesia and Nyasaland, r e l e a s e d 3 1 August 1955 ............

B o a r d of Inquiry M i n i s t r y of T r a n s p o r t and Communications, F e d e r a t i o n
79

14. - A m e r i c a n A i r l i n e s , Inc., Convair 240 a i r c r a f t , c r a s h e d n e a r Springfield,

M i s s o u r i , on 20 M a r c h 1955. Civil Aeronautics B o a r d (USA) Accident
Investigation R e p o r t No. SA-305, F i l e NO. 1-0038, r e l e a s e d 22 S e p t e m b e r
86

15. - B r i t i s h E u r o p e a n A i r w a y s Corporation, V i c k e r s Viscount, G-AMOL,

c r a s h e d on landing a t Copenhagen A i r p o r t , K a s t r u p , Denmark, on
25 M a r c h 1955. R e p o r t of D i r e c t o r a t e of Civil Aviation, Copenhagen,
r e l e a s e d 27 May 1955. ............................
16. - P a n A m e r i c a n W o r l d Airways, Inc., Boeing 377 a i r c r a f t , ditched i n t h e
P a c i f i c Ocean off t h e c o a s t of Oregon, on 26 M a r c h 1955. Civil Aero-
n a u t i c s B o a r d (USA) Accident Investigation R e p o r t No. SA-304,
F i l e NO. 1-0039, r e l e a s e d 15 November 1955. ...............
17. - Sikorsky 5-55 h e l i c o p t e r c r a s h e d s h o r t l y a f t e r taking off f r o m Burgeo,
Newfoundland, on 28 M a r c h 1955. Canadian D e p a r t m e n t of T r a n s p o r t
R e p o r t No. 55-15. ..............................
18. - United Air L i n e s , Lnc., DC-6 a i r c r a f t , c r a s h e d a t MacArthur Field,
Islip, N. Y., on 4 A p r i l 1955. Civil Aeronautics B o a r d (USA) Accident
Investigation R e p o r t NO. SA-306, F i l e No. 1-0071, r e l e a s e d 4 October
1955....... ...............................
19. - Eagle Aviation Company, Dakota DC-3 a i r c r a f t , G-AMYB, ground-
looped on landing r u n a t B e i r u t International A e r o d r o m e , Lebanon,
8 A p r i l 1955. A i r c r a f t Accident Report No. 15 r e l e a s e d by A i r Safety
a n d Accident Inquiry Department, M i n i s t r y of Public Works, D i r e c t o r a t e
of Civil Aviation, Lebanon ..........................
20. - Air India International Corporation, Bombay, Lockheed Constellation
749-A, v T - D E P , " K a s h m i r P r i n c e s s " , ditched following m i d - a i r explosion
i n South China S e a , off G r e a t Natuna I s l a n d s on 11 A p r i l 1955. R e p o r t by
M i n i s t r y of T r a n s p o r t and Communications. Republic of Indonesia,
r e l e a s e d 25 May 1955, ............................
21. - C h r i s t i a n and M i s s i o n a r y Alliance, S h o r t Sealand J Z - P T A , c r a s h e d on
mountain i n highlands of Netherlands New Guinea on 28 A p r i l 1955.
R e p o r t r e l e a s e d by D i r e c t o r of Civil Aviation, Netherlands New Guinea. ,

22, - Trans-Canada A i r l i n e s , Inc., V i c k e r s Viscount 724 a i r c r a f t , was

damaged on landing a t Winnipeg, Manitoba, on 16 May 1955, Canadian
Department of T r a n s p o r t R e p o r t No. 55-2 1 .................
 ICAO C i r c u l a r 50-AN/45 3

Page

23. - Douglas C-47, LV-ACQ, c r a s h e d a t Ri'o Chico A e r o d r o m e , Santa C r u z

T e r r i t o r y , Argentina, on 20 May 1955. Argentine Accident Investigation
R e p o r t No. 494, r e l e a s e d 17 November 1955 .................
24. - Associated Airways Limited, Avro York a i r c r a f t , CF-HMY, c r a s h e d on
take-off f r o m Edmonton A i r p o r t , A l b e r t a , Canada, on 26 May 1955.
R e p o r t by B o a r d of Inquiry appointed by M i n i s t e r of T r a n s p o r t .......
25. - N o r t h e a s t A i r l i n e s , Inc, , Douglas DC-3, o v e r s h o t t h e runway on landing
a t Lebanon, New H a m p s h i r e , on 3 1 May 1955. Civil A e r o n a u t i c s B o a r d
(USA) Accident Investigation Report, F i l e No. 1-0074, r e l e a s e d 3 1 August
1955 ......................................
26. - A s s o c i a t e d Airways Ltd., Lockheed 14-08, CF-TCI a i r c r a f t , c r a s h e d on
t e s t flight a t Winterburn, Alberta, 7 June 1955. R e p o r t No. 55-28
r e l e a s e d by Canadian D e p a r t m e n t of T r a n s p o r t , A i r S e r v i c e s B r a n c h ,
Civil Aviation Division. ............................
27. - P a n a i r do B r a z i l , S. A., Lockheed Constellation L-0-49, 00-PDJ, c r a s h e d
a t T r e s B o c a s , 12.9 k m southwest of Asuncion National A i r p o r t , Asuncion.
P a r a g u a y , on 16 June 1955. R e l e a s e d by D i r e c t o r a t e G e n e r a l of Civil
Aviation, P a r a g u a y . ..............................
28. - B r i t i s h O v e r s e a s Airways Corporation, De Havilland Dove 104, G-ALTM,
c r a s h landed outside t h e w e s t e r n boundary of London A i r p o r t , England,
on 22 June 1955. R e p o r t dated 9 D e c e m b e r 1955 r e l e a s e d by M i n i s t r y
of T r a n s p o r t and Civil Aviation (U. K. ) ....................
29. - T r a n s World A i r l i n e s , Inc., Douglas DC-3, and B a k e r Flying S e r v i c e ,
C e s s n a 140-A a i r c r a f t , collided 2 m i l e s NNW of F a i r f a x A i r p o r t Control
T o w e r , Kansas City, Kansas, M i s s o u r i , on 12 July 1955. Civil A e r o -
nautics B o a r d (USA) Accident Investigation R e p o r t SA-307, F i l e No. 1-0078
r e l e a s e d 11 J a n u a r y 1956 ...........................
30. - P o r t of New York Authority, B e l l helicopter 47G, c r a s h e d during take-off
f r o m heliport i n New York City, N. Y., on 13 July 1955. Civil A e r o -
n a u t i c s B o a r d (USA) Accident Investigation R e p o r t , F i l e No. 2-0019
r e l e a s e d 8 November 1955. ..........................
3 1. - Northwest A i r l i n e s , Inc. , DC-3 a i r c r a f t , collided with powerline pole
during a t t e m p t e d go-around a t Yakima A i r p o r t , Washington, on 15 July
1955. Civil Aeronautics B o a r d (USA) Accident Investigation Report,
F i l e No. 1-0077, r e l e a s e d 21 November 1955. ................
32. - Braniff Airways, Inc, , Convair 340 a i r c r a f t , c r a s h e d a t Midway A i r p o r t ,
Chicago, Illinois, on 17 July 1955. Civil Aeronautics B o a r d (USA)
Accident Investigation Report No. SA-308, F i l e No. 1-0081, r e l e a s e d
15 November 1955 ..................................
33. - B r i s t o l A i r c r a f t Company, B r i s t o l 171 M a r k IV, CF-HVX, accident a t
Vancouver A i r p o r t , B r i t i s h Columbia, Canada, on 19 July 1955. R e p o r t
r e l e a s e d by Canadian Department of T r a n s p o r t , Air services B r a n c h ,
Civil Aviation Division .............................
34. - C a m b r i a n Airways Limited, Dove DH 104 S e r i e s IB, G-AKSK, c r a s h e d a t
Sloden E n c l o s u r e , New F o r e s t , 1 1/2 m i l e s west of F r i t h a m , Hants., on
23 July 1955. M i n i s t r y of T r a n s p o r t a n d Civil Aviation (U. K. ) Aviation
Accident Report No. C636 ...........................
4 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 .
Page

35. - E l Al, I s r a e l A i r l i n e s Ltd., Lockheed Constellation 149, 4X-AKC, w a s

shot down n e a r t h e Bulgarian-Greek b o r d e r on 27 July 1955. R e p o r t
of C o m m i s s i o n of Inquiry, M i n i s t r y of Communications, S t a t e of I s r a e l ,
r e l e a s e d 18 August 1955 .......................... 146

36. - A m e r i c a n A i r l i n e s , Inc., Convair 240, c r a s h e d a t F o r t L e o n a r d Wood,

M i s s o u r i , on 4 August 1955. Civil Aeronautics B o a r d (USA) Accident
Investigation R e p o r t No. SA-309, F i l e No. 1-01 10, r e l e a s e d
9 December 1955. .............................
37. - Northwest A i r l i n e s , Inc., Boeing 377 a i r c r a f t , o v e r s h o t runway on
landing a t Chicago Midway A i r p o r t , Illinois, on 5 August 1955. Civil
Aeronautics B o a r d (USA) Accident Investigation R e p o r t F i l e No. 1-0091,
..........................
r e l e a s e d 9 J a n u a r y 1956

38. - F a i r w a y s ( J e r s e y ) L t d . , A v r o 19, G-AHIG, ditched i n t h e Solent R i v e r ,

England, on 6 August 1955. M i n i s t r y of T r a n s p o r t and Civil Aviation
(U. K. ), Civil Accident R e p o r t No. C637 .................
39. - DC-3, PP-CBY, c r a s h e d a t S e r r a do C a p a r a o , S t a t e of EspKrito Santo
on 26 August 1955. B r a z i l i a n C o m m e r c i a l Accident R e p o r t No. 3-C-55
published 1 November 1955 ........................
40. - Continental Air L i n e s Inc., DC-3, and Hines Flying S e r v i c e , P i p e r
PA-22, collided on f i n a l a p p r o a c h a t t h e L e a County A i r p o r t , Hobbs,
New Mexico, on 29 August 1955. Civil Aeronautics B o a r d (USA)
Accident Investigation Report SA-3 10, F i l e No. 1-011 1 r e l e a s e d on
11 J a n u a r y 1956 ..............................
41. - C u r r e y A i r T r a n s p o r t , Ltd., DC-3C, s t r u c k powerlines during
attempted e m e r g e n c y landing and c r a s h e d a t Lockheed Air T e r m i n a l ,
Burbank, California, on 8 S e p t e m b e r 1955. Civil Aeronautics B o a r d
(USA) Accident Investigation R e p o r t No. SA-312, F i l e No. 1-0109
r e l e a s e d 13 F e b r u a r y 1956. ........................
42. - Associated Airways Limited, B r i s t o l 170 Mk. 31, CF-GBT c r a s h e d
n e a r Thorhild, A l b e r t a , on 17 September 1955. R e p o r t No. 55-48
r e l e a s e d by Canadian D e p a r t m e n t of T r a n s p o r t , Air S e r v i c e s B r a n c h ,
Civil Aviation Division. ..........................
43. - B r i t i s h O v e r s e a s Airways Corporation, Argonaut a i r c r a f t , G-ALHL,
c r a s h e d on landing a t I d r i s A i r p o r t , Tripolitania, United Kingdom of
Libya, 21 September 1955. R e p o r t r e l e a s e d 15 October 1955 by
Ministry of Communications, L i b y a . ...................
44. - G r e a t L a k e s Carbon Corporation, Douglas A-26-C, c r a s h e d following
s t r u c t u r a l f a i l u r e resulting f r o m a m i d - a i r explosion n e a r Union City,
Oklahoma, on 3 October 1955. Civil Aeronautics B o a r d (USA)
Accident Investigation Report, F i l e No. 2-0058 r e l e a s e d 29 F e b r u a r y
1956 ....................................
45. - Jugoslowenski A e r o - T r a n s p o r t , Convair CV-340, YU-ADC, c r a s h e d on
the northwest slope of t h e Kahlenberg, 25 km. f r o m Wien-Schwechat
A i r p o r t , A u s t r i a , on 10 October 1955. Report r e l e a s e d by t h e
Accident Investigation Commission, Civil Aviation Office, F e d e r a l
Ministry of T r a n s p o r t and Nationalized I n d u s t r i e s , A u s t r i a , on
14 January 1956 ..............................
 ICAO C i r c u l a r 50-ANf45 - 5

Page

46. - Beech Bonanza, C-35, c r a s h e d into a p a r t m e n t building i n N o r t h

Hollywood, California, on 17 October 1955. Civil Aeronautics B o a r d

r e l e a s e d 9 M a r c h 1956 .. . . . . .. . . . . .... . ..... .. ..

(USA) Accident Investigation Report NO. SA-3 13, File NO. 2-0?50.
,
47. - United Air L i n e s , Inc., Dougaas DC-bB, exploded i n m i d - a i r n e a r
Longmont, Colorado, on 1 Naventber 1955. Civil Aeronautics B o a r d

14 May 1956. .. ... . . . . . . . . . . . . .. . . . ....... '

(USA) Accident Investigation Report, F i l e No. 1-0143 r e l e a s e d
, ,
48. - P e n i n s u l a r A i r T r a n s p o r t , Douglas c-54-DC c r a s h e d a t S e a t t l e ,
Washington, following take-off, 17 ~ o v e m b e r1955. Civil A e r o n a u t i c s

r e l e a s e d 3 May 1956 . . . .. . .. . . ... . .. . . ... . . ... .

B o a r d (USA) Accident Investigation R e p o r t SA-314, File NO. 1-0145
,
49. - S y r i a n Airways, DC-3, YK-AAD, burned i n hangar following explosion
a t D a m a s c u s A i r p o r t , S y r i a , on 22 November 1955. Report r e l e a s e d
...... . . .. ..... . ....
by D e p a r t m e n t of Civil Aviation, Ministry of Public Works a n d
Communications, Republic of S y r i a
50. - C-47, PP-CCC, c r a s h e d n e a r B e l & mA i r p o r t , ~ e l k m ,P a r 6 on

. ............ .............
1 D e c e m b e r 1955. B r a z i l i a n C o m m e r c i a l Accident R e p o r t No. 13-C-55,
r e l e a s e d 15 M a r c h 1956
51. - E a s t e r n A i r L i n e s , Inc., Lockheed Constellation, L-749-A, c r a s h e d on
final a p p r o a c h a t I m e s o n Airport, ~ a ~ k ~ o n v i l Fl leo,r i d a , on 21 D e c e m b e r
1955, Civil A e r o n a u t i c s B o a r d (USA) Accident Investigation R e p o r t
SA-315, F i l e No. 1-0169. R e l e a s e d 5 ~ e p t e m b e r1956. ... . . ....
52. - P a n A m e r i c a n World ,c\irways, I n c a , Douglas DC-7B1 l o s t powerplant
due t o f i r e i n flight n e a r Venice, Italy on 28 ~ e c e m b e r1955. Civil

. . . . . . . .. . .. . . . .. . . . . .. . . . .
Aeronautics B o a r d (USA) Accident Investigation Report, F i l e NO. 1-0178.
r e l e a s e d 3 1 May 1956

PART 11. - AIRCRAFT ACCIDENT STATISTICS .. . . .. * . . .. 9

Introduction . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . .
C h a r t showing p a s s e n g e r fatality r a t e t r e n d cornpared with growth i n t r a f f i c -
1945-1956 . . . . . . . . . . . . . . . . . . . . . . . * . . * . . . . . . . *

T a b l e on p a s s e n g e r f a t a l i t i e s - 1925 - 1956 . . . . . . . . . * . . . . . . .

T a b l e s A, B and C concerning 1955 . . . . . . . . , . . . . . . . . . . . . . .

A i r T r a n s p o r t Reporting Form G . , . . . . , . . . . . ... .. ....

PART 111. - PILOTS SAFETY EXCHANGE BULLETINS - "Wind Shear" . . . . . . . .
- " F l i c k e r Vertigow. . . . . .
PART IV. - LIST O F LAWS AND REGULATIONS. . . - ... . .... . *
THIS PAGE INTENTIONALLY LEFT BLANK
 ICAO C i r c u l a r 50 -AN145
FORE
Accident investigation i s recognized t o -
day a s one of the fundamental e l e m e n t s of
improved safety and accident prevention. Nearly
e v e r y accident contains evidence which, if c o r -
rectly identified and a s s e s s e d , will allow the
c a u s e to b e a s c e r t a i n e d s o that c o r r e c t i v e action
can be undertaken t o prevent f u r t h e r a c c i d e n t s
f r o m s i m i l a r c a u s e s . Thus, the ultimate object
of accident investigation and reporting, which
i s t o p e r m i t the comparison of many accident
r e p o r t s and t o o b s e r v e what c a u s e f a c t o r s tend
t o r e c u r , c a n be accomplished. These f a c t o r s
can then be c l e a r l y identified and brought t o the
attention of the responsible authorities.
The Accident Investigation Division of the
Air Navigation Committee of ICAO a t i t s f i r s t
s e s s i o n in 1946 recommended that States f o r -
ward copies of r e p o r t s of a i r c r a f t accident
investigations and inquiries, and aeronautical
publications and documents relating t o r e s e a r c h
and development work in the field of a i r c r a f t
accident investigation, t o ICAO in o r d e r that the
S e c r e t a r i a t might a p p r a i s e the information
gained and d i s s e m i n a t e the knowledge t o Con-
t r a c t i n g States.
The world-wide collection by ICAO of
accident r e p o r t s a n d aeronautical publications
and documents relating t o r e s e a r c h and d e v e l o p
ment work in the field of a i r c r a f t accident
investigation, and publication of the m a t e r i a l in
condensed f o r m , a s s i s t s S t a t e s and aeronautical
organizations in r e s e a r c h work in this field. By
stimulating and maintaining continuity of inter -
e s t in this problem the dissemination to indi-
viduals actively engaged in aviation of i n f o r m a -
tion on the actual c i r c u m s t a n c e s leading up t o
the accidents and of recommendations for a c c i -
dents prevention a l s o contributes t o the r e d u c -
tion of accidents.
The f i r s t s u m m a r y of accident r e p o r t s
and safety m a t e r i a l received f r o m States was
issued in October 1946 ( L i s t N O . 1 Doc 2177,
AIG156) under the title of "Consolidated L i s t of
publications and documents relating to A i r c r a f t
Accident Investigation R e p o r t s and P r o c e d u r e s ,
P r a c t i c e s , R e s e a r c h and Development Work in
the field of A i r c r a f t Accident Investigation
r e c e i v e d by the ICAO S e c r e t a r i a t f r o m Con-
tracting States". This was followed by f u r t h e r
s u m m a r i e s a t r e g u l a r i n t e r v a l s , the l a s t r e p o r t
being issued on 31 July 1950 ( L i s t No. 1 2 ,
Doc 7 0 2 6 , AIG/5 13). These s u m m a r y r e p o r t s
7
w e r e found t o b e of considerable technical i n t e r -
e s t t o S t a t e s , and in view of the l a r g e number of
r e q u e s t s for copies, i t was decided, e a r l y in
1951, to r e v i s e the method of publication and t o
produce t h e m a t e r i a l in the f u t u r e in the f o r m of
a n information c i r c u l a r entitled " A i r c r a f t Acci-
dent Digest".
The f i r s t Digest was i s s u e d in 195 1 under
the p r e s e n t title and with the new method of
presentation. Since ther), the usefulness of the
s e r i e s h a s continued t o elicit favourable c o m -
ment f r o m the a e r o n a u t i c a l world. I t i s hoped
that S t a t e s will c o - o p e r a t e t o the fullest extent
p e r m i t t e d by their national laws in the s u b m i s -
sion of m a t e r i a l for inclusion in future i s s u e s of
this Digest. It i s recognized that investigations
take a diversitv of f o r m s under the v a r i e t y of
constitutional dnd juridical s y s t e m s that e x i s t
throuehout the membershir, of ICAO and that. for
D
this r e a s o n , accident investigation p r e s e n t s one
of the m o s t difficult p r o b l e m s of standardization
in international civil aviation. At the s a m e t i m e
it i s a m o s t f r u i t f u l s o u r c e of m a t e r i a l for the
attainment of the objectives of the Chicago Con-
vention.
The usefulness of such a publication a s this
i s directly proportional to the thoroughness with
which accidents a r e investigated, the f r a n k n e s s
and impartiality of the findings, and t h e r e a d i n e s s
with which they a r e disclosed and a u t h o r i z e d t o
be published. It i s in t h i s way only that thls m o s t
f e r t i l e field for international co-operation c a n b e
effectively exploited. The m e a s u r e of i n t e r e s t
that t h i s publication h a s a r o u s e d , and the vital
information it i m p a r t s amply d e m o n s t r a t e the
possibilities of ultimate achievement when e v e r y
accident i s investigated with the g r e a t e s t thorough-
n e s s a n d the findings disclosed with corriplete
frankness.
The ICAO Manual of A i r c r a f t Accident
Investigation (Doc 6920 -AN/855), Second Edition)
h a s proved t o be a valuable guide in s e c u r i n g the
information r e q u i r e d for accldent prevention
m e a s u r e s , and, whether available f a c i l i t i e s and
r e s o u r c e s p e r m i t of the fullest investigation o r
not, if the Manual i s followed t o the g r e a t e s t
practicable extent, uniformity of findings and
their usefulness for the Digest will be enhanced.
Briefly, information should include:
1) A i r c r a f t Type;
2 ) State of K e g l s t r y ;
8 ICAO C i r c u l a r 50 - A v / 4 5
3 ) Date and P l a c e of Accident;
4) RCsumk of the Accident;
5) Result of the Technical Investiga-
tion;
6) Conclusions and R e c o m m e n d a -
tions ( i f any).
-
Note. N a m e s of p e r s o n s involved m a y b e
o m i t t e n t h o u t detracting f r o m the value of the
report.
Follow-up action and other supplementary
information o r c o m m e n t s on a n Accident R e p o r t
by the State of R e g i s t r y o r State of O c c u r r e n c e
may a l s o be submitted for inclusion in the D i g e s t .
R e s t r i c t i o n upon reproduction in the Digest
s e r i o u s l y i m p a i r s , of c o u r s e , the usefulness of
any r e p o r t s , a s it i s only by comparisonbetween
the c i r c u m s t a n c e s that occasioned the accident
and the c i r c u m s t a n c e s of other operations that
potentially hazardous c i r c u m s t a n c e s can be
f o r e s e e n and avoided.
The m a t e r i a l for this Digest h a s been
obtained f r o m v a r i o u s s o u r c e s , i s printed for
information only and does not n e c e s s a r i l y r e f l e c
t h e views of the International Civil Aviation
Organization.
P a r t I1 of this i s s u e dealing with A i r c r a f t
Accident S t a t i s t i c s mainly f o r the y e a r 1955,
h a s been b a s e d on m a t e r i a l d e r i v e d f o r the m o s t
p a r t f r o m t h e Air T r a n s p o r t Reporting F o r m s G
submitted by States. ( F o r f u r t h e r r e v i e w of
m a t e r i a l included r e f e r to the Introduction,
page 2 2 3 ) . The t a b l e s f o r 1955 are p r e s e n t e d
in the s a m e manner a s those appearing i n D i g e s t
No. 6 for the y e a r s 1952-1954 inclusive, a n d i t
i s t o be noted that r e v i s e d t a b l e s for 1954 have
been i s s u ~ dwith t h i s Digest.
P a r t 111 c o n s i s t s of two P i l o t s Safety
Exchange Bulletins, put out by Flight Safety
Foundation I n c . , dealing with the subjects of
"Windshear" arid "F'licker Vertigo". Due t o the
g r e a t number of r e p o r t s included in this i s s u e
i t h a s bepn n e c e s s a r y t o l i m i t the amount of
m a t e r l a l printed in this P a r t .
P a r t I V i s a complete l i s t of l a w s a n d
regulations relating to A i r c r a f t Accident Inves -
tigation and i n c o r p o r a t e s a l l a m e n d m e n t s t o the
l i s t preserited in Digest No. 5.
Whenever possible, photos and d i a g r a m s
have been obtained for illustration p u r p o s e s in
o r d e r to give a c l e a r e r over -all picture of the
c r a s h a r e a , an idea of the probable flight paths
of a i r c r a f t , the location of w i t n e s s e s to the
c r a s h , and in g e n e r a l to m a k e the r e p o r t s m o r e
interesting t o the r e a d e r .
 ICAO C i r c u l a r 50-AN145 9

COMMENTS ON ACCIDENT CLASSIFICATION TABLES AND

SUMMARY OF REPORTED ACCIDENT CAUSES - 1955

This i s s u e of the Digest contains 52 r e p o r t s Although considerable c a r e h a s been taken

of a i r c r a f t accidents occurring in 1955 p r e p a r e d in drawing up the t a b l e s t o e n s u r e that the informa-
f r o m r e p o r t s received f r o m States. tion contained t h e r e i n in no way a l t e r s the findings
of the r e p o r t s f r o m States, the v e r y brevity of
The Digest contains for the f i r s t time two the t a b l e s might give a wrong i m p r e s s i o n in s o m e
accident classification tables. The f i r s t (Table instances. The r e a d e r i s , t h e r e f o r e , invited
A) i s based p r i m a r i l y on the phase of operation always to r e f e r to the r e p o r t in the Digest.
and the second (Table B) on the c a u s e s of the
accidents. These tables a r e intended to p r o - A survey of the accident r e p o r t s for 1955
vide a comparative picture of reported a c c i - suggests that the following f e a t u r e s a r e worthy of
dents and to indicate any change in t r e n d s in attention:
operations, accident types, c a u s e s etc. The
stage of operation o r flight shown in the tables
i s that in which lay the apparent cause of the Table A
accident but not n e c e s s a r i l y the accident itself.
F o r example, in the c a s e of engine failure while
en route and resultant inability to maintain (i) Of the 45 accidents classified, the l a r g e s t
height with a subsequent c r a s h while executing percentages o c c u r r e d during the following
a forced landing, the accident i s classified a s phases of operation:-
"en route" .
en route 29% - 2% l e s s than the
The t e r m "undetermined" includes a l l 1954 percentage
accidents concerning the nature of which s o climb a f t e r
little evidence i s available that a definite c l a s - take -off 18% - 5070 due to pilot
sification could not be made. error
final approach 1870 - 50% due to 'other
These classifications closely follow the collisions
suggestions contained in the ICAO Manual of
A i r c r a f t Accident Investigation (Doc 6920- (ii) 2270 of a l l the accidents w e r e due to 'col-
ANf855). While the tables may s e r v e a useful lision with t e r r a i n ' and a f u r t h e r 2270 w e r e
purpose in indicating the cause t r e n d s , the due to 'other c o l l i s i o n s ~ .
figures a r e not significant for statistical pur -
poses and r e a d e r s a r e warned not to place too
much reliance on the t r e n d s indicated without Table B
comparison with other figures such a s those
published by national administrations. The
r e a s o n for t h i s i s that the classifications have ( i ) 51% of a l l accidents w e r e caused by pilot
been based on accident r e p o r t s which have been e r r o r - 970 l e s s than the 1954 percentage
founded on a variety of reporting and analyzing
techniques. Also the accidents r e p o r t e d in (ii) 1870 w e r e due t o m a t e r i a l f a i l u r e - 50% due
1955, and included in these classifications, do to engine trouble
not include a l l accidents that o c c u r r e d and that
were investigated during the y e a r ; only approx- ( i i i ) the breakdown for the remaining 3 170 was
imately 5070 of those investigated by States a r e a s follows:-
included in published r e p o r t s or s e n t to ICAO.
No effort h a s been made in this publication to errorsofotherpersonnel 1170
classify according to the type of operations weather' 9%
being conducted, for instance whether sched- miscellaneous 1 1%
uled, non-scheduled, a i r w o r k , or non-revenue
operations such a s testing, training or posi-
tioning. However, a notation on the type of An increasing number of r e p o r t s on h e l i -
operation being conducted, where known, i s copter accidents a r e being sent in to ICAO. At
included in Table A. p r e s e n t helicopter accidents a r e not included i n
10 ICAO C i r c u l a r 5 0 - A ~ / 4 5

the classification tables but a r e included in the and gives f u r t h e r information on the subject of
Digest for their technical information only. "fl'icker vertigo", based on actual experiences.

Report No. 46 mentions vertigo a s a Included in the 1955 accident r e p o r t s in

contributing factor to the accident. An article this Digest are those dealing with two mid-air
received f r o m the A i r T r a n s p o r t Division of the collisions, one a i r l i n e r which was shot down
Flight Safety Foundation i s included in P a r t 111 and two c a s e s of sabotage.
 TABLE A:- ACCIDENT CLASSIFICATION - 1955 (based on phase of o p e r a h o n )
Phase of TJ P2
ICAO
Operat1 or Type of Accident Apparent Cause Descrlptio~ Pa~e
~ef! Oper-
No. F?o. No. Eo. a tla*
f Grounl loop 1 Pilot error

CoLUsion u i t h t e r r a i n 1 PkscellaMoz~s
Tuwff
am
5 -
Pilot error

i Otner c o l l i s i o n s

Emergency c a d l ' b o n
3

-F~IVI-sof
1 &tend fdure
other persoanel

1 h e r h e a t i n g of r i g h t engme's r e a r m s t e r rod l e a t o
1 hlE 10.4
p.:1
1 ;-ifa5
hS

1iS
77
177

,
i
Irutiel
cli&
2 (innednie forced l a d i n g )

Stall 1 >laterial f a i l u r e
engine f a i l u r e a f t e r take-off.

1 Failure of f r o n t bearing of pro?eller shaft led t o sudden

stoppage of leL% engme.
1 PP.
1-55
I :s
21j

hrgency codltion 1 Erro-s of other personnel 1 h s s l o n s by m i n t e m a c e personnel cause5 a@. d n o s t 1 L3.'391 s 56

( ~ t forced
e landmg)

I a t rught 1 bal'~Of+ S 65 ii
I Coll+sion m t h terraio 2 Pilot error 2
reverse 1 Qr385 C 98
9
0
range ami a i r c r a f t becvne nncontrollable. (
-.3
I 8 Stall 1 Pilot error 1 Loss of conwol a t low a l t i t u d e - a r c r a f t was o v e r l o d e d . 1 AFL'&~7 T li6
C1
n

jE
dter

I
I
Tece-of f
h U i s l o u n t h other arcraft

&I frame ftulure in f l r g b t

1 Pilot error

1 Pilot error
1 Failure of DL3 crew to observe other a r c r a f t . and t o
comply with prescribe3 w o r t t r a f f l c pattern.

1 Loss of c o n t r o l durrng vhich a e s i @ stre%-th of s i r c r a f t

1 hVU0

1 ffi/U9
C
&(T$

NS
125
1%
ul
0
vas exceeded. Vertigo was a contributing factor. I
9
Explosion m fl+ght i bXscelLslleous 1 h d-te bomb e q l d e d in Lo. 4 bageege c o q e z t a e n t . 1 &'US S 20-

204
'z
.
4
Cther c o U l s i o n s 1 Errors of other personnel 1 Impz-operlp indexed propeller blades. 1 .@./@6 hS ul

I
1
SoLlision m t h other =craft 1 Pilot error 1 Operation of D L 3 in controi zone a s unham t r a f f i c 1 W375 BS
without clearance. &(S) 39

-P i l o t e r r o r D e n a t i o n from nornal procedures and from ainreps a t an

a l t i t u d e too low t o c l e a r ohatructio;ls ahead.
i bAJ392 S 74
2
Inproper operation on axthorrzed inshument f l i g h t . I PR s 172
C o L L s ~ o nv i t h tenaFtl 3 -55

/ Eihk *
Ymteriai f d u r e
1 While cLinbing t o b e t t e r v i s i b i l i t y co3ditrrons a i r c r a f t
was caught in adverse weather and struck a m m & i L I .

1 F a i l u r e of No. 3 p r o p e l l e r ard l o s s of No. 3 power p h t .

1 w378

1 BR/LOO
NS

S
11°

92
Emergency procedure
( h z e d l a t e forced h a d & ) P i l o t error 1 Fuel exhaustion due to madeqxate f h g h t plaaalng. 1 aR/u9 ss =m
Explosion of timed m f e r n a l machine m s t a r b o d vheel 1 w397 RS
Phcellaneons 2 w e l l punctured Wo. 3 f u e l tank aad a f i r e followed.
I
I
m l o a i o n and/or f i r e in f l i g h t 3

P S = Scheduled NS = Non-scheduled C = Check

lkterial failwe
flight Ti? :Training
Loss of enpencage due to infligtr. f u e l explosion.

1 Failure of 60. 3 propeller governor d r l v e shaft. lAT'~35 S

T = Test f l i g h t F = Filning f l i g h t A h = Argentine 1-LlptFn PR = P-'p e s e re;ort

I1
1 aR/u6 NS
,221
c
C
 TABLE A - ACCIDENT CLASSIFICATION - 1955 (based on phase of o p e r a t ~ o n )(cost'd)

Uiscellaneous

j Collision with t e r n

1 ' iduii:. ~ t i oi t i i r i aY.cn&

I
i jPilrf e r r o r

-7- - I

I ; ;S r d loop
I I j

I
Solizase o r r e t r r c t l m of
gear

I LP i i o t e r r o r
Undercarriage failed t o r e t r a c t on takeoff a d s e l e c t o r
s c t c b "as ~ e f iin jnpl position. U d e r c m l a g e r e t r a c M 1
on b d i n g .

oo high and t o o f a s t approach together with i n e f f e c t i v e

1 1 1
1 J-%'393

--
' ~ r r c r sof other personnel
1 I
1 Throttles vere closed on attenpted go-arolud and aircraft 1 kq40l S 1;5
s t n t c k a poverlins pole.
!-
* S = Schedi-lsd hS = boo-scneduled C: = C n e c k f l ~ g h t TP, = P a u u n g I= Test f l i g h t F = Frlning flight &/B = Argentine B a l l e t i n PR = Portuguese Report
d .%e Beport Bo. 27 for Brazilian comments.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 13

TABLE B : - ACCIDENT CLASSIFICATION - 1955 ( b a s e d on a c c i d e n t c a u s e s )

Cause No. Description KO.

-
- misused brakes and/or f l i g h t c o n t r o l s on t h e ground 1

- continued VFW i n t o unfavourable weather 1

- selected unsuitable t e r r a i n o r runway f o r landing 1

o r take-off

- misjudged distance 5
- improper operation on authorized instrument f l i g h t 4
Pilot error 23
- f a i l e d t o compensate f o r wind conditions 3
- misused power p l a n t o r power p l a h t c o n t r o l s 2

- exceeded operating l i m i t a t i o n 2

- f a i l e d t o observe other a i r c r a f t 2

- inadequate f l i g h t preparations 1

- attempted f l i g h t beyond a b i l i t y o r experience

- 1

Errors of other
personnel
5 - a i r c r a f t inadequately maintained 5

r-
- thunderstorm 1
Weather 4 - low c e i l i n g 1
- fog
- 2
-
- power p l a n t - p r o p e l l e r 3
Material f a i l u r e 8 - landing gear - main landing gear 1

- power p l a n t - engine
- 4

(explosion of timed i n f e r n a l machine) 2

Mlscellaneou~
- undetermined 1
5
- ( a i r c r a f t was attacked by j e t f i g h t e r s ) 1

- ( i n f l i g h t f u e l explosion) 1
-- --
THIS PAGE INTENTIONALLY LEFT BLANK
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 -
- 15

PART I

No. 1

Northwest A i r l i n e s , Douglas DC-4 a i r c r a f t c r a s h e d a t Sandspit,

B r i t i s h Columbia, Canada, on 19 J a n u a r y 1952, Civll Aeronautics
Board (USA) Accident Investigation Report No. SA-255, F i l e No. 1-0017.

( S e c r e t a r i a t Note: The following I S a supplement to the Clvil Aeronautics

B o a r d ' s accident Investigation r e p o r t r e l e a s e d 15 September 1952 - s e e
ICAO C i r c u l a r 3 1 - ~ ~ / 2-6A l r c r a f t Accident Digest No. 3, r e p o r t No. 3 3 . )

In accordance with the B o a r d ' s policy of keeping accident investigations open f o r c o n s l d e r -

ation of new evidence, continuing study was c a r r i e d out by the Bureau of Safety I n v e s t i g a t ~ o n
subsequent to r e l e a s e of the origlnal r e p o r t . This study resulted i n the d i s c l o s u r e of nose g e a r
malfunctions by revlew of s e r v l c e dlfficulties on DC-4 a i r c r a f t f o r a considerable perlod sub-
sequent to the accident, the development of additional f a c t s by detailed examination of the n o s e
g e a r wreckage of the subject a i r c r a f t , and the submittal of supplemental information relative to
the handling c h a r a c t e r i s t i c s of the DC-4 durlng take-off with t h r e e engines operatlng. Thus,
adoption was n e c e s s a r y of a r e v i s e d r e p o r t , r e l e a s e d 14 November 1955, c o n t a ~ n l n ga new
probable c a u s e .

Circumstances take-off was crosswind. ) Reasons f o r t h e s e

The flight c r a s h e d in Hecate S t r a l t l e s s
than a mile offshore following an attempted
precautionary landing at approximately
0138 h o u r s at the Sandspit, B r i t i s h Columbia
a i r s t r i p . Of the 40 p a s s e n g e r s and 3 c r e w
m e m b e r s , only seven p a s s e n g e r s survived.
The a i r c r a f t was substantially damaged upon
impact an ' subsequently was d e s t r o y e d by
actlon of tldes.
-
Investigation and Evidence
The nose g e a r of the a i r c r a f t washed up
on the beach s h o r t l y a f t e r the accident and was
l a t e r t r a n s p o r t e d to Seattle f o r c e r t a i n exam-
inations; following t h i s , it was forwarded to
Washington f o r detailed examination by Board
engineers. This l a t t e r examination disclosed
that the nose g e a r was r e t r a c t e d when t o r n
f r o m the a i r f r a m e . Normally, the nose wheel
r e t r a c t s before the main landing g e a r on thls
type a i r c r a f t , however, in the event of m a l -
function, it can r e t r a c t only partially.
malfunctions included broken s t e e r i n g c a b l e s ,
excessive s t e e r i n g paddle c l e a r a n c e s , rapld
g e a r r e t r a c t i o n due t o defective n o s e g e a r
o r i f ~ c e s ,and slow shock s t r u t extensions due
to over-tlght packings o r rough centerlng c a m s .
In this c a s e , the centerlng c a m s w e r e found to
be s a t i s f a c t o r y but the o t h e r p o s s l b i l ~ t l e s
r e m a i n indeterminable.
Runway length and condition a t Sandspit
w e r e s a t i s f a c t o r y to accommodate the DC-4,
and the c a p t a i n ' s decislon to land t h e r e w a s ,
t h e r e f o r e , in conformance wlth good operatlng
p r o c e d u r e s . Under the c i r c u m s t a n c e s of load,
speed, and braking conditions a t the t l m e , the
distance r e m a ~ n i n gon the runway f r o m polnt of
touchdown might be considered m a r g i n a l , and
a s u c c e s s f u l s t o p may o r may not have been
possible; the attempted go-around, t h e r e f o r e ,
m a y have been n e c e s s a r y .
Subsequent t o this accident, changes
relative to s u r v i v a l equipment and p r o c e d u r e s
were made in the Civil A l r R e g u l a t ~ o n s .

Review of s e r v i c e dlfficulties which Pllots would n o r m a l l y r e t r a c t flaps to

w e r e experienced on Northwest A ~ r l i n e s
DC-4's f o r a considerable perlod a f t e r this
accident disclosed a number of Instances in
which the nose g e a r failed to r e t r a c t fully.
All of the malfunctions o c c u r r e d In cold
weather operations and malnly durlng c r o s s -
wind take-offs whlch r e q u i r e nose wheel s t e e r -
ing a s do t h r e e englne take-offs. (The subject
15 d e g r e e s f o r a go-around. The d i v e r ' s
e s t i m a t e t h a t ' t h e flaps appeared to be down
about 40 d e g r e e s might be c o r r e c t ; however,
the flap posltlon m a y have shifted due t o tide
actlon o r towlng the a i r c r a f t backward. The
flap handle was found in the n e u t r a l positlon
which suggests that the pllot moved ~t f r o m the
full down posltlon and r e t r a c t e d flaps d u r ~ n g
16 ICAO C i r c u l a r
a c c e l e r a t i o n . None of the evidence on this
m a t t e r i s conclusive, but i f the f l a p s w e r e
a t 15 d e g r e e s , c l i m b p e r f o r m a n c e would
have been c o n s i d e r a b l y b e t t e r than a t a 40-
45 d e g r e e position.
At the r e q u e s t of the B o a r d , the
Douglas A i r c r a f t Company f u r n i s h e d a s e r i e s
o f c u r v e s plotting a i r speed v e r s u s r a t e of
c l l m b f o r a DC-4 o p e r a t i n g on t h r e e engines
a t rated take-off power and with the p r o p e l l e r
f e a t h e r e d on the inoperative engine. With-
out consideration of ground effect, these
c u r v e s w e r e computed f o r s e a Level a t a g r o s s
weight of 62 479 pounds, the e s t i m a t e d weight
o f the flight a t t h e t i m e of the a c c i d e n t . They
show that the b e s t r a t e of c l i m b w i t h 4 5 d e g r e e
f l a p s and landing g e a r down would be 15 f e e t
p e r minute a t approximateIy 98 m i l e s p e r h o u r ;
however, ground effect f o r a p p r o x i m a t e l y the
f i r s t fifty f e e t of altitude would i n c r e a s e the r a t e
of c l i m b appreciably. With 45 d e g r e e flaps,
g e a r up, the b e s t r a t e of c l i m b wouldbe 200 f e e t
p e r minute a t about 1 0 8 m i l e s p e r h o u r ; 420 f e e t
p e r minute could be r e a l i z e d with 30 d e g r e e
f l a p s , g e a r up, a t an a i r s p e e d of about 118 m i l e s
p e r hour. Thus, f r o m the t i m e the a i r c r a f t f i r s t
broke ground to the t i m e t h a t the landing g e a r
w a s fully r e t r a c t e d the r a t e of c l i m b would have
b e e n low. At a i r s p e e d s both below and above
t h o s e noted, the r a t e of c l i m b c u r v e s f a l l off
rapidly. In c o n s i d e r i n g t h e flight c h a r a c t e r i s -
t i c s of the a i r c r a f t a t the applicable weight, a
c l i m b would have been possible with f l a p s ex-
tended 40 to 45 d e g r e e s if p r o p e r a i r s p e e d s
w e r e maintained, t h r e e engines continuously
developed r a t e d take-off p o w e r , the a i r c r a f t
w a s f r e e of i c e , and the landing g e a r r e t r a c t e d
without malfunction.
ICAO Ref: ~ ~ / 1 9and
4 215
If malfunctioning o i the nose g e a r r e t r a c -
tion s y s t e m o c c u r r e d d u r i n g the a t t e m p t e d go-
a r o u n d i t i s likely to have c a u s e d f a i l u r e of the
r o d s actuating the n o s e wheel well d o o r s . The
d o o r s then could h a v e c a u s e d the buffeting
which one s u r v i v o r noticed. A p a r t i a l l y r e t r a c t -
ed n o s e g e a r would a l s o c a u s e d e t e r i o r a t i o n of
the c l i m b p e r f o r m a n c e . The evidence t h a t the
n o s e g e a r w a s t o r n f r o m the a i r c r a f t while i n
the up and locked position d o e s not p r e c l u d e
the p o s s i b i l i t y of malfunction. S e r v i c e expe-
r l e n c e i n d i c a t e s t h a t extension of the landlng
g e a r a f t e r nose g e a r malfunction, followed by
a s e c o n d r e t r a c t i o n , usually r e s u l t s in comple-
tion of the r e t r a c t i o n c y c l e . The t i m e i n t e r v a l
between the take-off and the c r a s h w a s prob-
ably sufficient f o r the above s e q u e n c e of e v e n t s .
The d i r e c t i o n a l controllability of the
DC-4 d u r i n g three-engine take-offs i s s u c h
t h a t t h e effect of a fully deflected r u d d e r i s
Insufficient to c o u n t e r a c t the turning m o m e n t
due to the u n s y m m e t r i c a l t h r u s t a t any s p e e d
a p p r e c i a b l y below the s a f e take-off s p e e d . As
a r e s u l t , pulling t h e n o s e wheel off the ground
i n a n a t t e m p t to take off a t t h e s e lower s p e e d s
r e s u l t s In the a i r c r a f t v e e r i n g off the runway.
Since, in this c a s e , the a i r c r a f t did not s t r i k e
the snow banks lining the runway, i t i s a p p a r e n t
that the take-off w a s not m a d e a t any s p e e d
a p p r e c i a b l y lower than the r e c o m m e n d e d take-
off and c l i m b s p e e d .
Probable Cause
The probable c a u s e of this accident was
a nose g e a r r e t r a c t i o n difficulty i n connection
with a n iclng condition o r a power l o s s , which
m a d e the a i r c r a f t incapable of maintaining flight.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
No. 2
( T h i s r e p o r t w a s r e c e i v e d too l a t e f o r inclusion in D i g e s t No. 6
c 9 5 4 a c c i d e n t g . Due to a 15-month p e r i o d of intensive
investigation i t w a s not adopted until 14 November 1955.)
Circumstances
- i n s t r u m e n t s . During the flight o v e r the North
The flight d e p a r t e d New York on 22
August 1954 f o r Schiphol A i r p o r t , A m s t e r d a m ,
with a s t o p a t Shannon. On b o a r d w e r e a c r e w
of 9 and 12 p a s s e n g e r s . At Shannon, following
a briefing on the e x p e c t e d en route w e a t h e r
conditions, the c r e w f i l e d a n IFR flight plan,
which indicated t h a t the f l i g h t w a s c l e a r e d a t
a c r u i s i n g altitude of 11 500 f e e t in Airway
" G r e e n 2" a t a t r u e a i r s p e e d of 256 knots.
Take-off f r o m Shannon was a t 0929 h o u r s
Greenwich Mean Time. P e r m i s s i o n w a s g r a n t -
e d to fly d i r e c t f r o m T u l s a to Rush-beacon by
which the roundabout way v i a Athlone w a s cut.
At 1122 the a i r c r a f t a d v i s e d that the boundary
of the Netherlands flight i n f o r m a t i o n r e g i o n had
b e e n c r o s s e d . At 11 25 the flight i n f o r m e d the
a r e a c o n t r o l c e n t r e a t Schiphol t h a t i t w a s
leaving the c r u i s i n g altitude a n d descending to
a p p r o a c h the beacon "Spijkerboor" (PHA) with
a n e s t i m a t e d t i m e of a r r i v a l a t 1 137. The
flight w a s then c l e a r e d to a p p r o a c h t h i s beacon
a t 5 500 f e e t o r above, l a t e r a m e n d e d to
4 500 f e e t o r above a n d then to 3 500 f e e t o r
above. E v e r y t h i n g up to t h i s point s e e m e d to
be quite n o r m a l a n d t h e r e was no indication of
a n y difficulty on board. At 1135 the a r e a
c o n t r o l c e n t r e a t Schiphol c l e a r e d the a i r c r a f t
to d e s c e n d to 2 500 f e e t but no a n s w e r w a s
r e c e i v e d . Half a n hour l a t e r the a l e r t i n g phase
w a s d e c l a r e d by Schiphol followed by the
e m e r g e n c y p h a s e . An extensive s e a r c h ( h a m -
p e r e d by low clouds, s h o w e r s and heavy s e a s )
w a s then s t a r t e d . Searching a i r c r a f t r e p o r t e d
a big o i l s p o t on t h e s e a off B e r g e n on the Sea
and a t 1610 floating d e b r i z w a s r e p o r t e d , s o m e
of i t showing the ~ n i t i a l sK L M . T h e r e w e r e no
survivors,
Investigation and E v i a e n c e
Weather conditions w e r e not d s f a v o u r a b i e
a s expected b e f o r e talce-off f r o m Shannon, but
c e r t a i n l y not unfdvorirable f o r a f l ~ g h ton
- 17
-
into
Sea a r e a the w e a t h e r w a s a s follows:
e x t e n s i v e f o r m a t i o n s of c l o u d s p r o d u c e d
an 8/8 c o v e r with i t s b a s e a t s o m e
h u n d r e d m e t r e s , and t h e r e w e r e many
s h o w e r s below t h i s level. Above t h i s
l a y e r , which extended a t a height of
1 600 - 1 800 m e t r e s (5 200 - 5 900 f e e t ) ,
many clouds e x i s t e d and i t i s p o s s i b l e
that t h e r e w a s a m o r e o r l e s s solid
c o v e r up to s o m e 3 500 m e t r e s (11 500
feet). Freezing level was a t an altitude
of 2 400 - 2 600 m e t r e s ( 7 900 - 8 500
feet).
B a s e d upon o b s e r v a t i o n s of c a p t a i n s of
o t h e r scheduled a i r c r a f t it i s known t h a t , i n
s p i t e of t h e s e c o m p r e h e n s i v e f o r m a t i c n s of
c l o u d s , t u r b u l e n c e w a s only s l i g h t to n i l , a n d
a l m o s t no s t a t i c i n r a d i o c o m m u n i c a t i o n w a s
e x p e r i e n c e d . Ice a c c r e t i o n w a s negligible.
A study of the w e a t h e r conditions led a l s o to
the conclusion t h a t the p r e s e n c e of thunder-
s t o r m s w a s hi hly unlikely. Wind a t s e a level
w a s 260 - 290714-18. At 14 500 f e e t the wind
e n c o u n t e r e d w a s 320/15
Some people n e a r the s m a l l town of
Egmond, w h e r e a i r w a y " G r e e n 2" c r o s s e s the
c o a s t of the N e t h e r l a n d s , i n f o r m e d the l o c a l
police, that they had o b s e r v e d a four-engined
p a s s e n g e r a i r c r a f t flying e x t r e m e l y low between
1 1 and 12 o l c l o ck. A thorough i n v e s t i g a t i o n
d i s c l o s e d that t h i s a i r c r a f t m u s t have been
PH-DFO. One w i t n e s s could give a ve-v
accurate time check a s his observation closely
followed the end of a c e r t a i n r a d i o p r o g r a m to
which he had been listening. H e m u s t have
o b s e r v e d the a i r c r a f t a t 1134 o r 1135, which
f i t s p e r f e c t l y well with the t i m e a t which
PH-DFO should have c r o s s e d the c o a s t a t t h a t
p l a c e . However, one w i t n e s s , whose s t a t e -
m e n t a l s o s e e m e d to be t r u s t w o r t h y had s e e n
the a i r c r a f t flying in a d i r e c t i o n which did not
fit in the a s s u m e d p a t t e r n . T h e r e f o r e , l t w a s
c o n s i d e r e d to be p o s s i b l e that the ilight path
18 ICAO C i r c u l a r
had been m o r e complicated and an extensive
s e a r c h f o r m o r e w ~ t n e s s e s ,which took s e v e r a l
weeks, was initiated, r e s u l t i n g in s o m e ninety
dependable s t a t e m e n t s . B a s e d upon t h e s e
o b s e r v a t i o n s the path of PH-DFO o v e r the
n o r t h e r n p a r t of Holland could be r e c o n s t r u c t e d
a p p r o x i m a t e l y up to the t i m e of 1201. At this
t i m e two quite independent w i t n e s s e s made the
s a m e o b s e r v a t i o n a t the s a m e t i m e , which could
be e x a c t l y e s t a b l i s h e d by c o m p a r i s o n with the
r a d i o p r o g r a m . Then the a i r c r a f t flew i n the
d i r e c t i o n of the s e a , and no o t h e r w i t n e s s e s
a r e available f o r this p a r t of the flight.
According to the s t a t e m e n t s , the plane
flew a t a height varying f r o m about 100 to
1 200 f e e t and except f o r the low altitude no
a b n o r m a l i t i e s w e r e o b s e r v e d . The flight
p a t t e r n , a s p e r f o r m e d by the a i r c r a f t , could
only have been flown if the c o n t r o l s w e r e m o r e
o r l e s s fully usable and if the a i r c r a f t w a s
flown by hand.
On 24 August a t t e m p t s to r e c o v e r the
w r e c k a g e of the a i r c r a f t w e r e commenced.
An a r e a of 150 s q u a r e m i l e s w a s thoroughly
and s y s t e m a t i c a l l y explored by Navy s h i p s and
fishing b o a t s . Sonor s w e e p s to locate the
wreckage proved to be unsuccessful due to the
g r e a t n u m b e r of m e t a l o b s t r u c t i o n s of wreck-
e d s h i p s and a l s o of a i r c r a f t f r o m the w a r .
T h e b e s t r e s u l t s w e r e obtained by t r a w l e r s
with r e i n f o r c e d fishing nets. In s p i t e of the
r e l a t i v e l y shallow s e a (approximately 60 f e e t ) ,
salvage action w a s h a m p e r e d by rough s e a s
throughout the autumn of that y e a r , i n which
weather in g e n e r a l had a n unsettled c h a r a c t e r .
The l a s t months of s e a r c h a c t i v i t i e s w e r e
a l m o s t without r e s u l t , and a s by then the favour-
able s e a s o n was o v e r , the salvage a c t i o n was
stopped on 25 November 1954 when 45 to 50%
of the a i r c r a f t had been brought a s h o r e .
The a i r c r a f t had been broken into many
thousands of p i e c e s , of which the cabin door
w a s the second biggest. All r e c o v e r e d p a r t s
w e r e t r a n s p o r t e d t o Schiphol A i r p o r t where a
detailed inspection of e a c h f r a g m e n t was
c a r r i e d out. F u r t h e r m o r e , a mock up of the
f u s e l a g e w a s made by m e a n s of a f r a m e w o r k ,
the tail and wing c o n s t r u c t i o n s being c a r e -
f u l l y l a i d out i n t h e i r r e l a t i v e positions.
As f r a g m e n t s of n e a r l y a l l main p a r t s of
t h e ship w e r e available, the conclusion was
r e a c h e d that a t the m o m e n t of Impact the a i r -
c r a f t must have been complete and that no
vital e l e m e n t s had been lost in flight. On the
r i g h t hand m a i n s p a r i t was found that defor-
m a t i o n w a s c a u s e d by f o r c e s In a n upward and
aft d i r e c t i o n , the l e f t hand wing f a i l e d i n f o r -
w a r d direction. Main p a r t s of the e n g i n e s
No. 3 and 4 and s o m e p a r t s of engines No. 1
and 2 w e r e found. T h e l o w e r c y l i n d e r s of the
r i g h t hand engines w e r e t o r n off, obviously by
i m p a c t . Investigation r e v e a l e d t h a t engines 2,
3 , and 4 m u s t have been running a t the m o m e n t
of i m p a c t and that engine No. 1 might p o s s i b l y
have r u n . It w a s i m p o s s i b l e to d e t e r m i n e a t
what power they w e r e running, t h e r e a r e indi-
c a t i o n s that t h i s w a s a t low power o r p e r h a p s
the power developed with c l o s e d t h r o t t l e s .
F r o m the p r o p e l l e r s only s e p a r a t e b l a d e s could
be r e c o v e r e d , two of these originating f r o m
p r o p e l l e r No. 4. The t i p s w e r e m i s s i n g and
the b l a d e s w e r e b r o k e n off i n a backward d i r e c -
tion n e a r the hub.
The deformation of the wreckage indicated
that the a i r c r a f t contacted the w a t e r with the
n o s e slightly down and slightly banking to the
right. Due to the f a c t that only m i n o r p a r t s of
the s y s t e m s could be r e c o v e r e d no conclusion
about t h e i r function p r i o r to the i m p a c t could
be d r a w n . None of the p a r t s showed any indi-
c a t i o n of f i r e . As no watch o r boardclock was
found the t l m e of i m p a c t r e m a i n e d unknown.
The examination of the r e c o v e r e d bodies
and p e r s o n a l p r o p e r t ~ e sof the v i c t i m s gave no
indication a s to the c a u s e of the accident. No
t r a c e s of f l r e w e r e found. The blood did not
contain C O L and no p a r t i c l e s of s o o t w e r e found
i n the bronchial tubes. The i n j u r i e s w e r e
c o n s i d e r e d to be p a r t l y vital and p a r t l y post-
m o r t a l , but no conclusion about the m i n i m u m
t i m e e l a p s e d between the vltal i n j u r i e s and the
d e a t h s could be drawn. P o s s i b l y both types of
i n j u r y originated during the i m p a c t with the
water.
The a l r c r a f t p a s s e d the Netherlands c o a s t
a t the t i m e expected, however, a t a v e r y low
altitude. This l e a d s to the conclusion t h a t v e r y
s h o r t l y a f t e r the l a s t r a d i o contact the r a t e of
d e s c e n t , intentional o r not, h a d been i n c r e a s e d
c o n s i d e r a b l y . No c l e a r a n c e was r e q u e s t e d f o r
t h i s d e s c e n t and f o r flying under IFR conditions
a t s u c h a n altitude. It 1s obvious, that t h e r e
m u s t have been a r e a s o n a b l e ground f o r this
action and i t is believed that t h i s p a r t of the
flight c o n t a l r ~ s,r:e key to the m y s t e r y . F u r t h e r -
m o r e , i t h a s not been possib1,e to find a r e a s o n -
a b l e explanatlon f o r the half-an-hour's fllght
o v e r land without any radlo contact, a f t e r the
f a s t d e s c e n t was made.
In tile evidence available no indication
could be found a s to the c a u s e of the accident.
In the opinion o! thc Investigator of Accidents
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
i t i s highly unlikely that the d i s a s t e r was due
to :
a ) the weather conditions, including ice
accretion and lightning;
b) any type of collision;
c ) ground-air firing;
d) failure of a powerplant, including blade
failure;
e ) failure of main s t r u c t u r a l p a r t s in
flight .
T h e r e a r e no indications that the sudden
descent was due to p a s s e n g e r s , c r e w condi-
tion o r loading. A failure in one of the
s y s t e m s (control, hydraulic, e l e c t r i c , oxygen,
fuel, cabin p r e s s u r e , emergency equipment)
cannot be excluded, but due to the fact that only
19
about 10% of the s y s t e m s were available f o r
inspection, i t i s impossible to b a s e any conclu-
sion upon the evidence.
A number of hypotheses a s to the cause of
the accident w e r e developed. Some possibilities
considered were: overheating of the e l e c t r i c
s y s t e m with heavy smoke development, explo-
sion of one of the high p r e s s u r e bottles, failure
of a cockpit window, failure of the automatic
pilot. However, no hypothesis could be formu-
lated in which a l l o c c u r r e n c e s and evidence
could be made reasonably acceptable. There-
f o r e , in November 1955, a f t e r a 15-months'
period of intensive investigation, the conclusion
had to be drawn that the c a u s e of the accident
could not be established.
Probable Cause
The Investigator of Accidents was unable
to determine the probable cause of the accident.
20 ICAO C i r c u l a r 5 0 - A N / ~ S

No. 3

K L M Royal Dutch A i r l i n e s , L o c k h e e d S u p e r C o n s t e l l a t i o n , c r a s h e d i n
the e s t u a r y of the R l v e r Shannon, I r e l a n d , o n 5 S e p t e m b e r 1 9 5 4 .
D e p a r t m e n t of I n d u s t r y a n d C o m m e r c e , I r e l a n d ,
Accident Investigation Report, r e l e a s e d
31 .Taniiarv 1955.

( T h i s r e p o r t w a s not i n c l u d e d i n D i g e s t No. 6
p 9 5 4 a c c i d e n t g a s ICAO w a s a w a i t i n g a n y
c o m m e n t s o n t h e I r i s h r e p o r t t h a t the N e t h e r l a n d s
G o v e r n m e n t m i g h t w i s h to m a k e . T h e s e h a v e
b e e n a d d e d a t the end of t h e r e p o r t . )

Gircumstances w h o s e e v i d e n c e c o u l d not be s h a k e n i n a n y way

The a i r c r a f t engaged on a scheduled
f l i g h t f r o m A m s t e r d a m t o New York took off
f r o m Shannon, a f t e r a s c h e d u l e d s t o p , a t
0230 h o u r s with a c r e w of t e n a n d f o r t y - s i x
p a s s e n g e r s . T h e take-off f r o m Runway 14/32
t o the s o u t h e a s t a p p e a r e d t o be n o r m a l up t o
lift-off s p e e d . T h i r t y - f i v e t o f o r t y s e c o n d s
l a t e r a n i n a d v e r t e n t but a l m o s t p e r f e c t d i t c h i n g
w a s m a d e i n the R i v e r Shannon, 8 170 f e e t f r o m
t h e d e p a r t u r e end of t h e r u n w a y u s e d . Twenty-
e i g h t l i v e s w e r e l o s t a n d the a i r c r a f t e v e n t u a l l y
b e c a m e a t o t a l l o s s t h r o u g h a c o m b i n a t i o n of
ditching, exposure and salvage operations.
Investigation and Evidence
T h e f l i g h t l e f t Shannon T e r m i n d l Building
a t 0230 h o u r s . It w a s p r o p e r l y loaded with f u e l
a n d l o a d d i s t r i b u t i o n w a s c o r r e c t , p l a c i n g the
c e n t r e of g r a v i t y within a c c e p t a b l e l i m i t s . It
w a s properly dispatched. The g r o s s load was
131 930 p o u n d s , well within t h e m a x i m u m allow-
a b l e t a k e -off weight.
T h e b e f o r e take-off run-up w a s c o m p l e t e d
i n take-off p o s i t i o n o n the a c t i v e r u n w a y , No. 14,
5 643 f e e t long.
Take-off w a s m a d e a t 0238. V. 1 s p e e d w a s
r e a c h e d a t 3 500 f e e t a n d lift-off a t 1 2 5 k n o t s
w a s m a d e j u s t o v e r the V. 2 s p e e d a t a p p r o x i -
m a t e l y 4 000 f e e t fro^. t h r e s h o l d . The f l i g h t
t h e n p a s s e d o v e r the r e m a i n i n g 1 600 f e e t of
runway i n a shallow climb, retracting i t s land-
i n g g e a r ; a p p r o a c h e d t h e 1 7 f o o t high e m b a n k -
m e n t 850 f e e t f u r t h e r o n a n d p a s s e d o v e r i t a t
a h e i g h t v a r i o u s l y e s t i m a t e d a t 20/80 f e e t .
A c c e p t a b l e e v i d e n c e t e n d e d to i n d l c a t e t h a t
p a s s a g e w a s v e r y low, h a v i n g i n m i n d a h e a v i l y
loaded a i r c r a f t in d a r k n e s s . X somewhat
s t e e p e r c l i m b w a s i n i t i a t e d a l m o s t c o l n c ~ d e n-
t a l l y with t h i s p a s s a g e . One ground w ~ t ~ i e s s
w a s s o c o n c e r n e d t h a t he w a s i n s t r u n ~ e n t a li n
i n i t i a t i n g a c a l l t o t h e S e c u r i t y F o r c e s when h e
f e l t t h a t t h e a i r c r a f t h a d "gone i n t o t h e Shannon".
T h i s w i t n e s s , a c u s t o m s o f f i c e r , with t h r e e a n d
a half y e a r s 1 s e r v i c e a t Shannon, w a s a t t r a c t e d ,
j u s t l f i a b l y o r o t h e r w i s e , by what h e c o n s i d e r e d
unusual engine sound and exhaust f l a m e a s the
a i r c r a f t g a t h e r e d s p e e d d u r i n g take-off. He,
t h e r e f o r e , p a r t i c u l a r l y o b s e r v e d t h e take-off,
initial s h a l l o w c l i m b a n d p a s s a g e o v e r t h e
e m b a n k m e n t . T h e i n i t i a t i o n of a s o m e w h a t
s t e e p e r c l i m b w a s followed a l m o s t i n l m e d i a t e l y
by a s h a l l o w d e s c e n t ( i n h i s own w o r d s : "A
g r a d u a l glide11)t o a point w h e r e the f l i g h t d i s -
a p p e a r e d behind the F i r e S t a t i o n , which i n t e r -
r u p t e d h i s line of s i g h t .
Up t o t h l s polnt o b s e r v a t i o n had b e e n
m a d e f r o m a v a n t a g e polnt j u s t i n s i d e the
T e r m i n a l A u l l d ~ n g . Such c o n c e r n w a s f e l t t h a t
the w i t n e s s went o u t s i d e , a c c o m p a n i e d by
a n o t h e r c u s t o m s o f f i c e r , t o s e e if the f l i g h t
would r e a p p e a r . It dld n o t a n d i t w a s then t h a t
the previously mentioned call was initiated.
A s n o a c t i o n of a n e n l e r g e n c y n a t u r e f o l l o w e d
a t t h e F ~ r eS t a t i o n ( t h e A i r p o r t R e s c u e Head-
q u a r t e r s ) the witness a s s u m e d he had been
mistaken.
T h e d u r a t i o n of the flight w a s a b o u t 31
s e c o n d s f r o m the tltric 1 1 p a s s e d o v e r the e n d
of the r u n w a y until t h e a l r c r a f t f i r s t c o n t a c t e d
the w a t e r i n a tall-down s l i g h t l y rlght-wing-
low a t t i t u d e . It t h e n cover'ed a c e r t a i n d i s t a n c e
t o a point 7 350 f e e t i r o r n the r u n w a y , w h e r e ~t
shed ~ t N s o s . 3 and 4 p r o p e l l e r s , comtng to
r e s t o n the Middle G r o u n d , a s h a l l o w m u d b a n k ,
l o s i n g N o s . ? a n d 4 e n g i n e s a p p r o x i m a t e l y 200
a n d 100 f e e t b e f o r e doing s o , a t a t o t a l d l s t a n c e
ot 8 170 f t ~ ftr o l r l t h e end of Runway 14. T h e
aircraft l r i colnplcte d a r k n e s s alrnost
 ICAO C i r c u l a r
i m m e d i a t e l y , a s the flight e n g i n e e r switched
off the m a s t e r e l e c t r i c a l switch. The cockpit
e m e r g e n c y lighting failed a s the b a t t e r y
"drowned". The flight could not have exceed-
e d a t any s t a g e a t r u e height of 170 feet.
T o t a l flight t i m e h a s been v a r i o u s l y
e s t i m a t e d a t 32-42 s e c o n d s . Thirty-nine s e c -
onds a p p e a r f r o m r e c o n s t r u c t i o n to be r e a s o n -
a b l e . In t h i s 39 s e c o n d s a n u m b e r of commands
affecting changing f l i g h t configuration w e r e
given:
a ) c o m m a n d g e a r up a t 125 knots,
b) c o m m a n d f i r s t reduction ( M E T 0
power) a t 140 knots;
c ) c o m m a n d f l a p s up a t 150 knots;
d ) c o m m a n d c l i m b power a t 160 knots.
Seconds a f t e r c o m m a n d c l i m b p o w e r , f i r s t
contact with the w a t e r , d e s c r i b e d a s a " s h i v e r "
o r a "shudder", and l a s t i n g 3-5 s e c o n d s , w a s
m a d e . T h i s was followed by s e v e r a l heavy
bumps, which a p p e a r to have been the f i r s t
indication of trouble to a l l c r e w m e m b e r s ex-
cept the ca$tain, who had d e t e c t e d difficulty
v e r y s h o r t l y before the "shiver", a p p a r e n t l y
m o r e f r o m instinct than o t h e r w i s e .
T h e c a p t a i n ' s and f i r s t o f f i c e r ' s evidence,
r e l a t i v e to the v a r i o u s c o m m a n d s and s p e e d s
connected with t h i s flight, coincide f a i r l y well.
T h e i r s t a t e m e n t s on altitude, however, cannot
be r e c o n c i l e d . The captain s t a t e d a l a s t ob-
s e r v e d top altitude of 250 feet and climbing
(acceptable only on the b a s i s of a possible 100
foot a l t i m e t e r e r r o r ) , p r i o r t o seeing, just b e f o r e
the c r a s h , an a l t i m e t e r reading of 100 f e e t and
r a t e of c l i m b indicator showing a d e s c e n t p a s s -
ing through 1 000 f e e t p e r minute. The f i r s t
officer s t a t e d n o r m a l flight climbing, a t a l a s t
o b s e r v e d altitude of 600 f e e t . T h i s was h i s
l a s t i n s t r u m e n t reading p r i o r to (he s t a t e d )
placing the landing g e a r l e v e r f r o m "up" posi-
tion to "neutral", and picking up h i s check l i s t
p r e p a r a t o r y to calling the a f t e r take-off check.
No r e c o n s t r u c t i o n i s possible with s u c h a height
(600 f e e t ) between lift-off and touchdown. F o r
t h i s r e a s o n , c o n s i d e r a b l e evir!ence w a s r e q u i r e d
i n connection with flight l n s t r u l n e n t s t a t i c and
p r e s s u r e "plumb~ng". It w a s i m p o s s i b l e to r e c -
oncile the s t a t e d position of the landing g e a r
l e v e r . On f i r s t inspection of the wrecked a i r -
c t a f t i t w a s found i n the "up" position. It was
generally a g r e e d that owing to de5ign f e a t u r e s
of this l e v e r , it could not be rr~ovedby a c c t d e n t
f r o m the "neutral" position.
The initial investigation of the w r e c k e d air-
c r a f t tended to indicate that the landing g e a r had
been up a n d locked a t the t i m e of ditching a n d
that although the left m a i n wheel r e m a i n e d i n
i t s up-lock, the n o s e wheel and r i g h t wheel had,
a t s o m e l a t e r t i m e , c o m e out of t h e i r up-lock
condition. Close examination of the up-loc k s
o n the S u p e r Constellation will show that once
the up-locks a r e engaged, s e v e r e d a m a g e would
o c c u r to the up-lock m e c h a n i s m if f o r c i b l y r e -
l e a s e d . They could be r e l e a s e d h y d r a u l i c a l l y ,
o r through s e v e r e d e c e l e r a t i o n f o r c e s a c t i n g on
the hydraulic piston of the up-lock. Owing to
the type of s y s t e m involved t h i s a p p e a r e d to
have been i m p o s s i b l e in t h i s c a s e . The up-
l o c k s f o r nose a n d r i g h t m a i n wheels w e r e ,
p r a c t i c a l l y speaking, undamaged. It was con-
cluded that the left wheel w a s up a n d locked and
t h a t f o r a l l p r a c t i c a l p u r p o s e s the nose and
r i g h t m a i n wheels w e r e up but had not been
locked when the hydraulic s y s t e m f a i l e d to func-
tion a s Nos. 3 and 4 engines t o r e loose f r o m the
r i g h t wing, a t the t i m e of ditching.
Note. - The landing g e a r and f l a p s operated
f r o m t h e s e c o n d a r y hydraulic s y s t e m supplied
by h y d r a u l i c p u m p s d r i v e n f r o m Nos. 3 and 4
engines.
The wing f l a p s w e r e up a t t i m e of ditching.
T h e landing g e a r should be up and locked p r i o r
to initiation of f l a p r e t r a c t i o n . T h e f a c t that the
a i r c r a f t w a s not found i n t h i s configuration c a l l -
e d f o r explanation and c o n s i d e r a b l e investigation
a s follows:
a ) Was the take-off m a d e with f l a p s
up r a t h e r than in the take-off p o s i t i o n ?
It h a s been e s t a b l i s h e d f r o m flight t e s t
data that the t i m e f o r landing g e a r r e t r a c -
tion v a r i e s f r o m a m l n i m u m of 9 to a
m a x i m u m of 25 s e c o n d s . It i s a p p a r e n t
that on a flight totalling 32 to 42 s e c o n d s
t h e r e w a s a m p l e t i m e f o r the landing
g e a r alone to be r e t r a c t e d if the f l a p s
had not been in take-off position. T h i s
c o n f i r m s c r e w evidence that f l a p s w e r e
in the p r o p e r take-off configuration.
b) Were the f l a p s s e l e c t e d to "up"
by m i s t a k e a t c o m m a n d " g e a r up"? If
t h i s rnistake w a s made and landing g e a r
s e l e c t e d "up" s h o r t l y a f t e r the e r r o r w a s
noted, the a i r c r a f t , having b e e n lifted off
the ground a t 125 knots would have p a s s e d
the embankment low a n d a c c e l e r a t i n g and
lost lift a p p r o x i m a t e l y 10 s e c o n d s a l t e r
lift-off, a s the f l a p s w e r e in the final
s t a g e s of r e t r a c t i o n . It would then have
touched down in a nose-up attitude a s the
landing g e a r was finally r e t r a c t i n g , quite
beyond the c o n t r o l a b ~ l i t yof the captain.
22 ICAO C i r c u l a r
T h e C o u r t , a w a r e that this type of
mishandling h a s o c c u r r e d on other type
a i r c r a f t in the p a s t , c o n s i d e r e d the pos-
sibility should not go unquestioned. The
c r e w evidence denying s u c h mishandling
was accepted.
c ) Were the f l a p s s e l e c t e d "up"
inadvertently p r i o r to completion of land-
ing g e a r r e t r a c t i o n ? T h e r e d light which
i n d i c a t e s that the landing g e a r i s unlocked
and/or i n a t r a n s i e n t condition was r e -
moved f r o m the a i r c r a f t , t e s t e d and found
b u r n e d out. Although not wholly s a t i s f i e d
with the method of r e m o v a l and checking
af the bulb in question, the C o u r t a c c e p t s
that i t had burned o u t during landing g e a r
r e t r a c t i o n giving a f a l s e indication of
landing g e a r "up".
Under s u c h a condition during take-
off, and while the landing g e a r w a s r e -
t r a c ting, acceleration to flap-up s p e e d
would have been m a d e and the "flaps up"
o r d e r given.
It was found f r o m t e s t flight data
that when f l a p s a r e s e l e c t e d while the
landing g e a r is i n the r e t r a c t i n g s t a g e the
f l a p s will f i r s t r e t r a c t delaying the land-
ing g e a r and, i n s o m e c a s e s , allow r e -
extension. The joint o p e r a t i o n f l a p s-
up, landing g e a r up - t a k e s 34-38 seconds.
It is quite possible that t h i s did o c c u r ,
t h e r e b y c a u s i n g unexpected d r a g , c r e a t i n g
a condition wholly unexpected by the cap-
tain. P e r f o r m a n c e of the Super Constella-
tion, loaded to full g r o s s weight, is s u c h ,
that t h i s situation could r e a s o n a b l y have
b e e n handled with adequate safety. Conse-
quently the Court c a n only c o n s i d e r the
condition r e f e r r e d to a s contributing to
but not the c a u s e of the a c c i d e n t ,
Reconstruction of the m o s t probable flight
path of the a i r c r a f t , b a s e d on f a c t s and sub-
m i s s i o n s a c c e p t e d and i n f e r e n c e s d r a w n by the
C o u r t , with accompanying c o m m e n t s and con-
side ration i s a s follows.
P o i n t of unstick; s p e e d of unstick; point
of contact with the w a t e r ; s p e e d s a t v a r i o u s
c o m m a n d s have been taken a s s t a t e d ante.
The wreckage was found about 650 feet
to the left of a projection of the c e n t r e l i n e of
Runway 14/32. The a i r c r a f t , a f t e r take-off,
probably followed a slightly m o r e e a s t e r l y
c o u r s e than the c e n t r e l i n e of the runway and
the bank, r e f e r r e d to e a r l i e r , was origindled
only a s h o r t lllile before the ditching.
The d i r e c t i o n of the f u s e l a g e was a t a n
adgle of about 60° e a s t of the c o u r s e of the a i r -
craft.
While i t i s c l e a r that the a i r c r a f t m u s t
have hit the w a t e r , with s o m e s t a r b o a r d bank,
in a s o u t h e a s t e r l y c o u r s e , the C o u r t r e j e c t s
the opinion that i t made a 270 d e g r e e t u r n be-
f o r e coming to r e s t , a s such a t u r n would have
affected p a s s e n g e r s and c r e w m u c h m o r e than
they w e r e in f a c t affected. It h a s been taken,
t h e r e f o r e , that the a i r c r a f t c a m e to r e s t in a
more o r l e s s southerly direction, partially
r e s t i n g on the mud and p a r t i a l l y floating, and
that the tide movement a t the t i m e of the d i s -
a s t e r c a u s e d the a i r c r a f t to t u r n through about
90 d e g r e e s to i t s final position. A rough c a l -
culation shows t h a t , a s s u m i n g the a i r c r a f t m a d e
f i r s t contact with the w a t e r a t a n a i r s p e e d of
170 knots (ground s p e e d of about 158 knots),
a p p r o x i m a t e l y a t the point s o m e 300 f e e t before
the p r o p e l l e r s w e r e found, the t l m e e l a p s e d
between this point and reaching the final posi-
tion of the wreck would have been about 9 s e c -
onds. T h l s i s justified by the t i m e o b s e r v a t i o n s
m a d e by s e v e r a l w i t n e s s e s on the sequence of
s h u d d e r , bumps and so-called i m p a c t and final
coming to r e s t . The a v e r a g e d e c e l e r a t i o n m u s t
then have been . 9 g .
The C o u r t c o n s i d e r e d that the a i r c r a f t
followed a flight path somewhat a s r e c o n s t r u c t e d
in F i g , 1. This i s b a s e d on the c a l c u l a t i o n s
( t h e s e a r e s e t out i n the o r i g i n a l R e p o r t a s
Appendix V) taken f r o m the a p p r o p r i a t e evidence
a c c e p t e d by the C o u r t and taking into account the
following f a c t o r s .
I n s t r u m e n t E r r o r s : As rough c a l c u l a t i o n s
showed the i m p o s s i b i l i t y of the a i r c r a f t having
e v e r r e a c h e d the height of 250 f e e t ( a s o b s e r v e d
by the captain) the p o s s i b l e e r r o r of this i n s -
t r u m e n t w a s examined. S e v e r a l e r r o r s -all
aggregable - w e r e found. They w e r e a s follows:
a ) According to check s h e e t s sub-
m i t t e d by K L M a n a l t i m e t e r check w a s
made a t Schiphol on 4 S e p t e m b e r , when
the a i r c r a f t was p r e p a r e d f o r the flight.
The c a p t a i n ' s a l t i m e t e r then showed a
s e t t i n g of 101 3 . 8 mb a t a b a r o m e t r i c
p r e s s u r e of 1014.8 mb. T h i s i n s t r u m e n t
e r r o r could thus account f o r a possible
reading of 1 rnb (28 fket) too high.
b) T h e c a p t a i n ' s a l t i m e t e r before
the take-off a t Shannon a p p e a r e d to be
s e t a t 1010.3 mb whilst the official s e t t i n g
(uNH) p a s s e d to PH-LKY before take-off
w a s 1009.6 and the a c t u a l b a r o m e t r i c
p r e s s u r e eight m i n u t e s b e f o r e take-off
( 0 2 39 h o u r s ) a p p e a r e d to have been
lOU9. 3 rllL.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
T h i s difference between a c t u a l b a r o m e t r i c
p r e s s u r e and the c a p t a i n ' s a l t i m e t e r setting
could have accounted f o r a possible of
1 m b (28 f e e t ) too high.
c ) According to Document 1939
m e a s u r e m e n t s made by the National A e r o -
nautical R e s e a r c h Institute, A m s t e r d a m ,
o n the so-called "position e r r o r s " of the
s t a t i c s y s t e m of L . 1049 a i r c r a f t show
that a t s p e e d s f r o m about 120 knots to
150 knots, f l a p s i n take-off position ( i r -
r e s p e c t i v e of landing g e a r position) and
a t s p e e d s of about 160 knots, f l a p s "up",
a position e r r o r of about 30 to 50 f e e t ,
a l t i m e t e r reading too high, c a n be ex-
pected. This i s different f r o m the previous-
ly existing d a t a which showed that in t h i s
r a n g e of s p e e d s , e r r o r s of about 10 f e e t
only might be expected. However, taking
into account that the t e s t s in A m s t e r d a m
have been m a d e c a r e f u l l y , i t was accepted
that a n e r r o r of 30 to 50 f e e t ( a l t i m e t e r
too high) due to position e r r o r might be
possible.
The e r r o r s mentioned under a ) , b)
and c ) above, which a l l have to be added,
r e s u l t in a p o s s i b l e total e r r o r of about
90 to 100 f e e t in the c a p t a i n ' s a l t i m e t e r ,
reading too high, during the take-off.
Thus i t i s c o n s i d e r e d that about 160 f e e t
w a s the g
- r e a t e s t t r u e altitude a c t u a l l y
reached.
P e r f o r m a n c e C h a r a c t e r i s t i c s : Assuming
that the Rear minht not in f a c t have been in the
"up" position when f l a p r e t r a c t i o n was o r d e r e d ,
i t followed that the a i r c r a f t would have had a
slowly r e t r a c t i n g landing g e a r . A p o s s i b i l i t y
e x i s t e d that the p e r f o r m a n c e of the a i r c r a f t ,
climbing a t M E T 0 power, w a s not fully up to
L. 1049 s t a n d a r d . T h e r e f o r e , i n making c a l -
culations f o r the flight path, slightly lower
p e r f o r m a n c e h a s been allowed f o r .
The Climb: It was c o n s i d e r e d that the
evidence c a n f a i r l y be i n t e r p r e t e d by an e s t i -
m a t e of a n a v e r a g e r a t e of i n i t i a l c l i m b of
150 ft. / m i n . , a height of 36 f e e t p a s s i n g the
-
>* R e p o r t on Lockheed L. 1045 C Super Constellation. Pitot-Static P r e s s u r e Deviations in
Take-off and Initial Climb by F.E. Douwes Dekker - R e p o r t V. 1749, Natlondl Aeronautical
R e s e a r c h Institute, A m s t e r d a m .
** O b s e r v a t i o n s on the Influence of E'lap H e t r a r t l o n on Gear R e t r a c t i o n T ~ t n e- KI,M R e s e a r c h
Department. I L S / M V M / D ~ C .16, 1954.
23
e m D d n k m e n t * and a Veed 140 a t 12-
1 3 s e c o n d s a f t e r unstick. Durlng t h a t i n i t i a l
c l i m b , s a y t h r e e s e c o n d s a f t e r unstick, iand-
ing g e a r r e t r a c t i o n would have been o r d e r e d .
At about t h e t i m e of c r o s s i n n the e m b a n k m e n t
a much s t e e p e r c l i m b w a s s e t up and M E T 0
power w a s o r d e r e d . Assuming that a r o u n d
3-4 s e c o n d s l a t e r M E T 0 power w a s s e t and the
s p e e d i n c r e a s e d to 144 knots 15-16 s e c o n d s a f t e r
unstick, a m o r e o r l e s s s t e a d y c l i m b would
probably then have taken p l a c e , which i s e s t i -
m a t e d a t 530 ft. /min. and t h i s i s r e a s o n a b l y
justified by the evidence of a r a t e of between
500 and 600 f e e t p e r minute. The t r u e indi-
c a t e d s p e e d of 149 knots (which a c c o r d i n g to
Lockheed d a t a could have been shown on the
a i r s p e e d i n d i c a t o r a s 150 knots) would have
been r e a c h e d a t a t r u e height of 140 f e e t con-
f o r m i n g to a probable a l t i m e t e r r e a d i n g , a s i t
a p p e a r e d to the captain, of a r o u n d 230 f e e t .
F r o m then on s o m e m o r e c l i m b ( s a y about
30 f e e t ) would have been p e r f o r m e d but this
would have been coupled with a f l a p r e t r a c t i o n
and i s d e a l t with l a t e r .
The T r a n s i t i o n between A s c e n t and De-
s c e n t and the F l a ~ R e t r a c t i o n : The Descent:
T h e r e was a grddually c u r v e d path between
c l i m b and d e s c e n t (no sudden v e r t i c a l a c c e l e r a -
tions o r o t h e r i r r e g u l a r i t i e s w e r e noticed by
a n y c r e w m e m b e r between a i r s p e e d s of 150 to
160 knots). During t h i s p e r i o d f l a p r e t r a c t i o n
w a s initiated.
On the b a s i s of a re-extension of the land-
ing g e a r , a s d e s c r i b e d e a r l i e r , having o c c u r r e d ,
the r e s u l t s of the t e s t s submitted i n Doc. 22799
w e r e used to e s t i m a t e the flight path between
a s c e n t and d e s c e n t .
F r o m a point, where during c l i m b a
s p e e d of 150 knots was r e a c h e d , i t was a s s u m e d
that a flight path, a c c o r d i n g to the t e s t s of
Doc. 227, w a s followed, which path then g r a d -
ually p r o c e e d e d to the descending flight path.
F l a p r e t r a c t i o n would then, a c c o r d i n g to the
t e s t s mentioned, have been initiated about two
s e c o n d s b e f o r e the t r u e indicated a i r s p e e d of
150 knots, 1. e . , a t a s p e e d of 149 knots (whlch
could, however, a s s t a t e d e a r l i e r , have been
shown on t h e c a p t a i n ' s a i r s p e e d i n d i c a t o r a s
150 k n o t s ) .
24 ICAO Circular
The r a t e of descent of an a v e r a g e of
1 200 f t . / m i n . , conforms with the captain's
evidence of a n indicated r a t e , passing through
1 000 ft. /min. (which with the known appreciable
lag in the r a t e of climb indicator, denoted a
higher t r u e r a t e of descent). The a i r s p e e d of
160-1 65 knots likewise a g r e e s with the evidence
of indicated a i r s p e e d s .
A s u r f a c e headwind of 12 knots r e p o r t e d
a t time of take-off was allowed f o r . The usual
variation of wind with height, a s well a s mo-
m e n t a r y deviations f r o m the r e p o r t e d value of
the s u r f a c e headwind could well account f o r a
shortening of this flight path by s o m e hundreds
of feet. The final p a r t of the flight path, t h e r e -
f o r e , could well have been somewhat m o r e
flattened out, thus allowing f o r a point of f i r s t
contact s o m e hundreds of f e e t before the point
actually shown in F i g . 1.
In r e g a r d to the descent, the Court con-
s i d e r e d the possibility of a lift disturbing
action during this p a r t of the flight. No ev-
idence, however, could be found t o support
such a disturbance. Examination of the wreck
did not r e v e a l any condition which could have
c a u s e d i t . Nor was there any evidence of the
vibrations o r buffeting which would be expected
a t an e a r l i e r stage of the flight f r o m such a
condition.
If a re-extension of the landing g e a r took
place, a f t e r flap selection, the landing g e a r
m u s t normally have had a r e t r a c t i o n time of
around 25 seconds, which i s f a i r l y long but not
inconsistent with evidence on r e t r a c t i o n t i m e s
of other a i r c r a f t of the s a m e type (Doc. 231*)
showing c a s e s of 23 and 25 s e c o n d s . F u r t h e r -
m o r e , flap r e t r a c t i o n time m u s t have been
around 12 seconds which i s f a i r l y s h o r t but
again not inconsistent with data given in the
s a m e document, showing some c a s e s of 12 and
13 seconds flap r e t r a c t i o n t i m e . Moreover,
the conclusion that in this c a s e flap r e t r a c t i o n
w a s f a i r l y quick i s c o r r o b o r a t e d by evidence
f r o m the co-pilot.
* Report on Retraction T i m e s of G e a r and
F l a p s on KLM Super Constellations departed
f r o m Schiphol during the period f r o m Dec. 25,
1954 until J a n , 3, 1955 - F. H. van Weydom'
C l a t e r b o s . Schiphol. Jan. 3, 1955.
F r o m the data of this flight path, the
a p p t o x i m a t e i n s t r u m e n t indications, available
to the captain, f r o m f l a p r e t r a c t i o n onwards,
w e r e computed.
It w a s o b s e r v e d that the a i r s p e e d indi-
c a t o r indicated a gradual i n c r e a s e in speed,
which, in general, i s not uncommon during
flap retraction. The r a t e a t which speed w a s
i n c r e a s i n g , a s f a r a s i t c a n be judged f r o m the
a i r s p e e d indicator, would c e r t a i n l y not have
shown anything a b n o r m a l to the captain f o r
about the f i r s t 10 seconds a f t e r f l a p r e t r a c t i o n .
The a l t i m e t e r would have shown h i m f o r
about the f i r s t 9 seconds f r o m flap r e t r a c t i o n
a n indication n e a r l y a t , o r slightly above, 250
feet " s e v e r a l times" and a f t e r that a gradual
d e c r e a s e of altitude.
The r a t e of c l i m b indicator should have
been indicating f o r about the f i r s t 9 seconds a
r a t e of climb, a t f i r s t staying around 500 feet
p e r minute and l a t e r on d e c r e a s i n g gradually,
until about the eleventh second a f t e r "flap up"
selection, when i t should have shown about
l e v e l flight and f r o m then on a descent a t a n
e v e r i n c r e a s i n g r a t e . To the captain, who was
not a w a r e that a descent of considerable r a t e
had a l r e a d y begun and thus had no r e a s o n to
s u s p e c t a n i n c r e a s i n g d e g r e e of lag in the r a t e
of c l i m b indication, this i n s t r u m e n t , in the
f i r s t 9 seconds a f t e r flap r e t r a c t i o n , could have
conveyed the e r r o n e o u s i m p r e s s i o n of a gradual-
ly flattening flight path, to be followed by a m o r e
b r l e s s horizontal flight a t the end of flap r e t r a c -
tion.
The a r t i f i c i a l horizon should have shown
h i m a t the initiation of flap r e t r a c t i o n a c e r t a i n
nose-up attitude conforming with the climb he
had been performing before flap r e t r a c t i o n
s t a r t e d . A nose-up attitude change f r o m t h i s
moment on f o r about 4 seconds should have
been a p p a r e n t in conformity with the action
taken by the captain to c o r r e c t the a i r c r a f t ' s
attitude f o r flap r e t r a c t i o n .
However, a t about 6 s e c o n d s a f t e r flap
r e t r a c t i o n s t a r t e d the horizon indication should
have begun to show an a i r c r a f t attitude lower
than the nose-up position during the climb p r e -
ceding the flap selection. ,
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
T h i s nose-down movement of the indica-
tion should have continued f o r about 3 m o r e
s e c o n d s until i t m o r e o r l e s s s e t t l e d to a condi-
tion conforming to about 4 d e g r e e s of attitude
l o w e r than the attitude in the c l i m b p r e c e d i n g
f l a p selection. ( T h i s attitude c o r r e s p o n d s with
a s t i l l slightly nose-up o r about l e v e l position
of the f u s e l a g e r e f e r e n c e line, c e r t a i n l y not
with a m a r k e d nose-down attitude. )
It m a y have been about the eleventh second
a f t e r f l a p s e l e c t i o n that C l i m b P o w e r was o r d e r -
e d . The a l t i m e t e r m a y then have shown about
200 f e e t and the r a t e of c l i m b i n d i c a t o r m a y have
been moving through about z e r o . In the next one
o r two s e c o n d s , however, the r a t e of c l i m b
i n d i c a t o r ought to have been showing a n a p p r e -
c i a b l e r a t e of d e s c e n t whilst the a l t i m e t e r should
have continued to show the downward movement
a t a n e v e r i n c r e a s i n g r a t e . The t r u e d e s c e n t
w a s then about fully developed and i t m u s t have
been a t t h l s m o m e n t that the captain, a c c o r d i n g
to his s t a t e m e n t , r e a l i z e d that t h e r e w a s s o m e -
thing e n t i r e l y wrong. He then took d e c i s i v e
r e c o v e r y a c t i o n pulling the c o n t r o l columri v e r y
f i r m l y , which gave h i m probably the i m p r e s s i o n
of a pronounced "stiffening up" of the e l e v a t o r
c o n t r o l . It i s quite c l e a r that a p a r t f r o m a nose-
up movement on h i s horizon, none of the n o r m a l
flight i n s t r u m e n t s could have given h i m , in the
few s e c o n d s that r e m a i n e d before the contact
with the w a t e r , any indication of a r e s p o n s e of
the a i r c r a f t to h i s c o n t r o l movement.
The Report then c o n s i d e r e d what explana-
tion could ae given f o r the above d e s c r i b e d events
and f o r the a c t i o n s of the captain.
In t h i s r e s p e c t , i n the f i r s t p l a c e , atten-
tion was d r a w n to the f a c t that the e v e n t s which
had a n i m m e d i a t e and d i r e c t b e a r i n g on the
final d i s a s t e r began to develop a t the moment
of flap r e t r a c t i o n , that i s only about 15 s e c o n d s
b e f o r e the m o m e n t of contact with the w a t e r .
The f i r s t indication of the n e c e s s i t y f o r
c o r r e c t i v e action o n h i s p a r t should have been
glven by h i s h o r i z o n displaying a definite low-
e r i n g of the n o s e , though not indicating a nose-
down attitude.
The o c c u r r e n c e of this attitude change,
notwithstanding a positive nose-up c o r r e c t i n g
action f o r f l a p r e t r a c t i o n taken by h i m s e v e r a l
25
s e c o n d s e a r l i e r , m u s t v e r y probably have been
p r o m o t e d by the f a c t that the landing g e a r w a s
i n the c o u r s e of re-extension, which, a s w a s
brought f o r w a r d in e v i d e n c e , i s likely to c a u s e
the a i r c r a f t to have a tendency to l o w e r the n o s e ,
and p o s s i b l y by the f a c t that the c a p t a i n did not
r e t r i m the a i r c r a f t f o r f l a p r e t r a c t i o n .
E v e n if the change of attitude to a m o r e
o r l e s s l e v e l position had not been noticed
i m m e d i a t e l y by the captain, the f i r s t indica-
tions of a d e s c e n t could have been noticed about
3 s e c o n d s l a t e r on the a l t i m e t e r . The f a c t that
a t t h a t m o m e n t a s c a n of h i s i n s t r u m e n t s h a d
not yet r e v e a l e d to h i m a n u n d e s i r a b l e flight
condition m u s t be a t t r i b u t e d t o one o r both of
the following c a u s e s :
a ) A f t e r the f i r s t 5 o r 6 s e c o n d s
of clirllb, when hc is a c c u s t o m e d to s c a n
h i s i n s t r u m e n t s l e s s continuously, the
c a p t a i n ' s o b s e r v a t i o n s of the horizon and
( p a r t i c u l a r l y a f t e r 250 f e e t indicated) the
a l t i m e t e r m o v e m e n t s w e r e inadequate;
he placed too much r e l i a n c e on the r a t e
of c l i m b i n d i c a t o r .
b) He did not, to the full extent,
a p p r e c i a t e the anticipating c h a r a c t e r of
the h o r i z o n indication, in that a change
of the horizon b a r position i n d i c a t e s a
change of flight conditions which willnot
become a p p a r e n t f r o m the o t h e r i n s t r u -
m e n t s until s o m e s e c o n d s l a t e r . The
f a c t that s o m e p i l o t s , i n t h i s r e s p e c t ,
fail to gain the f u l l e s t p r o f i t of the o b s e r -
vation of the horizon w a s brought f o r w a r d
in evidence.
The captain o r d e r e d c l i m b p o w e r a t a
s p e e d of 160 knots and i m m e d i a t e l y a f t e r w a r d s
f e l t that t h e r e w a s something e n t i r e l y wrong.
He w a s l a t e r convinced t h e d e s c e n t had a l r e a d y
begun, before he gave this o r d e r . This con-
veyed to the C o u r t that he did not o b s e r v e h i s
altimeter for some seconds before ordering
c l i m b power.
When he d e t e c t e d the f a t a l flying condi-
tion he took d e c i s i v e action i m m e d i a t e l y but
nothing then could have p r e v e n t e d the accident.
The a c t i o n taken w a s f o r t u n a t e l y just i n t i m e
to p r e v e n t a h e a v i e r impact.
26 ICAO C i r c u l a r
Other f a c t o r s contributed to the accident.
In the f i r s t place a p r o p e r setting of the captain's
a l t i m e t e r before take-off would have reduced
the e r r o r of h i s instrument by about 20 feet.
Secondly, the climb performance of this a i r -
c r a f t w a s not utilized by the captain to the extent
possible.
If the captain had concentrated l e s s on
building up speed and m o r e on gaining height
in take-off, he would have had a b e t t e r oppor-
tunity f o r coping with unexpected incidents.
He was a t a f u r t h e r disadvantage in dealing
with unexpected h a z a r d s , in his stated assump-
tion that 250 f e e t indicated altitude placed h i m
in a position of sufficient safety against a l l
known take-off r i s k s .
T h e r e i s no question of individual o r
collective experience. Evidence during the
investigation, and the v e r y n a t u r e of the a c c i -
dent, focused attention on a number of i t e m s
and actions which a ) a p p e a r e d a t variance with
the Manufacturer's and Company's instructions
and b) a p p e a r e d to be a t v a r i a n c e with b a s i c
r e q u i r e m e n t s of a n o p e r a t o r of Scheduled I n t e r -
national Air Services.
1) The captain a g r e e d that the flight
engineer could abandon take-off, up to
V. 1 speed, on h i s own initiative.
2) The chief flight engineer stated
that i t was n o r m a l p r a c t i c e to switch in
g e n e r a t o r s individually, a s each engine
was s t a r t e d .
3) The flight engineer stated that
i t w a s h i s p r a c t i c e to switch off automatic
feathering, immediately a f t e r reduction
to M E T 0 power, (i. e. a t v e r y low alti - ed on a r e g u l a r e n route flight,
tude on initial climb).
4) The captain's a l t i m e t e r , a s
found, was not s e t a t the official baro-
m e t r i c p r e s s u r e , c u r r e n t a t take-off.
5) The landing lights w e r e found
"off" but in the "extended" position.
Neither pilot could s t a t e if they were used
during take-off. (Evidence indicated no
definite practice. )
6) Though not n e c e s s a r i l y a t
variance with Company policy, the Court
was i m p r e s s e d with the captain's emphasls
on the d e s i r e f o r speed r a t h e r than c l i m b ,
p a r t i c u l a r l y in the e a r l y s t a g e s a f t e r
take-off. This technique, coupled wlth a
s t a t e d c o n c e r n i n connection with the use
of take-off power, "with these highly
s t r u n g engines1', could have an a d v e r s e
effect on the c o u r s e of events during the
take-off of heavily loaded a i r c r a f t .
7) The second pilot had initial
difficulty opening the f o r w a r d e n t r a n c e
door until the third pilot r e m e m b e r e d that
i t was n e c e s s a r y to p r e s s a device to un-
.
lock the handle. One of the s u r v i v o r s (a
p a s s e n g e r who gave evidence) s t a t e d that
the cabin c r e w had difficulty with the r e a r
m a i n entrance door. In h i s own words:
"The s t e w a r d e s s s a i d to us that we should
keep quiet and everything i s a l l right, and
hen they w e r e h a m m e r i n g on the door to
open it; they w e r e pushing with t h e i r
shoulder against the door and that i s the
l a s t I h e a r d . ' I (It i s significant that on
Super Constellation a i r c r a f t this door
opens inwards. )
8) The flight radio o p e r a t o r ' s l a s t
e m e r g e n c y ditching d r i l l w a s 31 March
1954. He had not had any type of "dry
run" ditching, o r e m e r g e n c y d r i l l in
Super Constellations. Written i n s t r u c -
tions only had been available.
9) The instrument rating renewal
of KLM pilots i s accomplished within
Netherlands regulations by a combina-
tion of
a ) An i n s t r u m e n t check which
1s accomplished in a Link T r a i n e r ;
b) Conducting a periodic pro-
ficiency check which i s acccomplish-
c ) Indicating to the licensing
authority that the applicant f o r
ratlng renewal i s c u r r e n t l y in fact
e x e r c i s i n g the rights of h i s licence
( i . e , dolng sufficient actual flying).
10) The captain, on 31 July 1953,
completed a conversion c o u r s e on
Lockheed Super Constellation a i r c r a f t ,
consisting of s i x h o u r s flying and c e r t a i n
technical ground school s u b j e c t s . Be -
tween that date and 5 September 1954 a
perlodlc proficiency check was conducted
on 2 5 January lC)54by a check pilot while
en route ~ n l s t r r d a r n / ~ e York.
w An
lnstrurrlent check ( ~ the n Link T r a i n e r )
was completed on 2 5 March 1954.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
11) The f l r s t officer completed co-
pilot conversion training on Super Con-
s t e l l a t i o n a i r c r a f t o n 1 4 J u l y 1953 consist-
ing of 1 h o u r 30 m i n u t e s f l y i n g a n d c e r t a i n
technical ground school subjects. P r e v i o u s
t o t h l s , o n 27 J u n e 1950, c o - p i l o t c o n v e r -
sion training had been completed on the
s m a l l e r C o n s t e l l a t i o n , Model L 749,
c o n s i s t i n g of 7 h o u r s 0 3 m i n u t e s flying.
T h e r e i s no r e c o r d of a n y r e c u r r i n g flight
training o r checking between these dates.
An i n s t r u m e n t check (in a Link T r a i n e r )
w a s c o m p l e t e d o n 1 2 F e b r u a r y 1954 f o r
licensing purposes. A captain's transi-
tion t r a i n i n g c o u r s e o n C o n v a i r 240 a n d
C o n v a i r 340 type a i r c r a f t w a s c o m p l e t e d
o n 27 May 1954 c o n s i s t i n g of 4 h o u r s 25
m i n u t e s flying.
T h e f i r s t o f f i c e r , h o w e v e r , is a
c a p t a i n i n h i s own r i g h t a n d h a d a p p a r e n t -
l y , f r o m 1 8 S e p t e m b e r 1949, b e e n flying
D C - 3 a i r c r a f t in t h a t c a p a c i t y . He h a d
not h a d a n y p e r i o d i c p r o f i c i e n c y c h e c k s
in this period.
During the t h r e e months previous
t o t h i s a c c i d e n t the f i r s t o f f l c e r had flown
either a s captain and/or f i r s t officer on
five d i f f e r e n t t y p e s of a i r c r a f t .
In c o n n e c t ~ o nwith a n y consideration of
c r e w competency, respecting a Scheduled Air
C a r r i e r , i t is c o n s i d e r e d r e l e v a n t to quote f r o m
ICAO Anne 6:
"The p r e s e n t e d i t i o n of Annex 6
contains Standards and Recommended
P r a c t i c e s a d o p t e d by t h e I n t e r n a t i o n a l
C i v i l Aviation O r g a n i z a t l o n a s the
m i n i m u m Standards appllcable to the
o p e r a t i o n of a i r c r a f t i n s c h e d u l e d i n t e r -
national a i r s e r v i c e s , e t c . l1
"4.2. 7. 2. S. An o p e r a t o r s h a l l
e n s u r e t h a t pilotlng technique a n d the
a b i l i t y to e x e c u t e e m e r g e n c y p r o c e d u r e s
i s c h e c k e d in s u c h a w a y a s t o d e m o n -
s t r a t e the c o m p e t e n c e of h i s p i l o t s . S u c h
c h e c k s s h a l l be p e r f o r m e d twice within
a n y p e r i o d of o n e y e a r . Any two s u c h
c h e c k s which a r e s i m i l a r a n d w h i c h o c c u r
within a p e r i o d of f o u r c o n s e c u t i v e m o n t h s
s h a l l not a l o n e s a t l s f y t h i s r e q u i r e m e n t .
27
"4.2. 7.5 An o p e r a t o r s h a l l e n s u r e
that all c r e w m e m b e r s a r e instructed and
p e r i o d i c a l l y e x a m i n e d i n the u s e of the
e m e r g e n c y and life-saving equipment
r e q u i r e d t o be c a r r i e d a n d t h a t t h e y a r e
d r i l l e d i n e m e r g e n c y e v a c u a t i o n of the
a i r c r a f t used. I t
P i l o t s : T h e C o u r t i s of t h e opinion t h a t
t h e a m o u n t of c h e c k i n g d o n e , though f o r m a l l y
c o m p l y i n g with t h e O p e r a t o r s 1 L i c e n s i n g Au-
thority's requirements, f o r instrument rating
renewal:
a ) Does not fully s a t i s f y the inten-
t i o n of the a p p l l c a b l e p o r t i o n s of A n n e x 6
of t h e ICAO.
b) D o e s not r e p r e s e n t t h e a m o u n t
of r e c u r r i n g t r a i n i n g a n d / o r c h e c k i n g
r e q u i r e d , f o r the m a n y a n d v a r i e d p r o -
c e d u r e s t h a t p i l o t s of m o d e r n t r a n s p o r t
a l r c r a f t a r e lnvolved wlth.
Flight Engineers: T h e r e is apparently
no f o r m a l r e q u i r e m e n t to e n s u r e m a i n t e n a n c e
of f l i g h t e n g i n e e r c o m p e t e n c y . T h e a p p l i c a b l e
c r e w s t a t i o n o n m o d e r n a i r c r a f t is i m p o r t a n t
a n d i n v o l v e s c o m p l e x p r o c e d u r e s . It w a s t h e
C o u r t ' s opinion t h a t t h e r e is a n e c e s s i t y f o r
p e r i o d i c infllght c h e c k i n g of a s u p e r v i s o r y
n a t u r e in o r d e r to maintain competency. ( T h i s
recommendation is n o t i n t e n d e d to i m p l y t h a t
the f l i g h t e n g i n e e r o n t h i s f l i g h t h a d a n y r e -
s p o n s i b i l i t y f o r the a c c i d e n t ) .
C r e w ( G e n e r a l ) : Making d u e a l l o w a n c e s
f o r the e f f e c t s of l l a f t e r - c a s t i n g " , the e v i d e n c e
n e v e r t h e l e s s s u g g e s t e d i n s u f f i c i e n c y of d r i l l
"in erne r g e n c y e v a c u a t i o n of the a i r c r a f t u s e d . "
Probable Cause
T h e p r o b a b l e c a u s e of t h e a c c i d e n t w a s
a s follows:
1) F a i l u r e of t h e c a p t a i n t o c o r r e l a t e
and interpret his instrument indications prop-
e r l y d u r i n g f l a p r e t r a c t i o n , r e s u l t i n g in n e c -
e s s a r y a c t i o n not b e i n g t a k e n i n s u f f i c i e n t
tlme.
28 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
This £allure was partially accounted for
by the e f f e c t o n i n s t r u r n e n t i n d i c a t i o n s of i n a d -
v e r t e n t a n d u n e x p e c t e d landing g e a r r e - e x t e n -
sion.
2) L o s s of a i r c r a f t p e r f o r m a n c e due to
i n a d v e r t e n t landing g e a r r e - e x t e n s i o n .
3) T h e c a p t a i n f a i l e d t o m a i n t a i n s u f f i -
c i e n t c l i m b to give h i m a n o p p o r t u n i t y of m e e t -
ing u n e x p e c t e d o c c u r r e n c e s.
RECOMMENDATIONS
It i s r e c o m m e n d e d :
1) Thai warning o r signdl lights, indi-
c a t i n g a n unlocked o r t r a n s i e n t c o n d i t i o n of th-
landing g e a r , a s o n the L o c k h e e d lU49 S u p e r
C o n s t e l l a t i o n , be d u p l i c a t e d .
2) T h a t self-sufficient e m e r g e n c y light-
ing be p r o v i d e d i n passenger a c c o m m o d a t i o n of
transport category a ~ r c r a f t .
3 ) R e s p e c t f u l l y t h a t r e g u l a t i o n s be
a d o p t e d a t t h e e a r l i e s t d a t e s p e c i f y i n g "Stand-
a r d s f o r e n s u r i n g t h a t h o l d e r s of the i n s t r u m e n t ( i . e . , the c o n t r o l t o w e r ) n o d o u b t t h e s u s p i c i o n
r a t ~ n gm a i n t a i n t h e i r c o m p e t e n c y " . (See : Note t h a t a d i s a s t e r m i g h t h a v e o c c u r r e d in t h e vi-
t o ICAO, 3 r d E d i t i o n , A p r i l 1953, Annex 1,
P a r a . 2.11.1.3).
4 ) T h a t f l a s h l i g h t s f o r u s e of f l i g h t c r e w l n f l u e n c c d the GCA D i r e c t o r to be m o r e g u a r d e d
p e r s o n n e l be s o d e s i g n e d t h a t t h e y m a y be func
t i o n a l while l e a v i n g the h a n d s f r e e .
5) T h a t f l i g h t p e r s o n n e l be m d d e a w a r e
of the d a n g e r t h a t a p o w e r - o n d i t c h i n g rnay
r e m o v e p o w e r p l a n t s f r o m the w i n g s , in t u r n
c a u s i n g d a m d g e to the wings a n d p o s s i b l e l o s s
of d i n g h i e s s t o w e d t h e r e i n .
6) T h a t f l i g h t p e r s o n n e l a n d a l l o t h e r
s e r v i c e s c o n c e r n e d , be m a d e a w a r e of the
e x t r e m e d a n g e r of f u m e s i n a c o n f i n e d s p a c e ,
s u c h as t h e c a b i n of a n a i r c r a f t , r e s u l t i n g
f r o m i n g r e s s ( o r in-flow) of p e t r o l .
7) T h a t p o r t a b l e oxygen e q u i p m e n t f o r
e m e r g e n c y u s e by m o r e than one c r e w m e m b e r
be available o n t r a n s p o r t c a t e g o r y a i r c r a f t .
Search and Rescue
T h e C o u r t w a s s a t i s f i e d t h a t a f t e r the
a i r c r a f t h a d b e c o m e a i r b o r n e a t 0238 h o u r s a n d
h a d p a s s e d o u t o v e r the e m b a n k m e n t , the A i r
Traffic Control Service w e r e under the i m p r e s -
s i o n t h a t t h e a i r c r a f t w a s s t i l l f l y i n g but h a d
developed a complete radio failure, a n i m p r e s -
s i o n s t r e n g t h e n e d b y t h e e r r o n e o u s r e p o r t of
i d e n t i f i c a t i o n by t h e CCA D i r e c t o r . T h e i r
m a i n t a s k , t h e r e f o r e , b e c a m e o n e of t r y i n g to
re-establish radio communication f o r Control
p u r p o s e s . But f o r u n a w a r e n e s s of the r e p o r t
t h a t a w i t n e s s h a d s u s p e c t e d t h a t the a i r c r a f t
w a s in d a n g e r a f t e r take-off, a n d the l a t e r
e r r o n e o u s r e p o r t f r o m the C C A D i r e c t o r , the
c o n t r o l o f f i c e r i n t h e t o w e r undoubtedly would
h a v e i n v e s t i g a t e d t h e p o s s i b i l i t y of the a i r c r a f t
belng down. On the o t h e r hand, the S e c t i o n
L e a d e r of the S e c u r i t y F o r c e w a s s a t i s f i e d t h a t
nothing w a s a r r i i s s , when, upon r e c e i p t of t h e
telephone r e p o r t , h e looked out o v e r the r i v e r
a n d s a w o r h e a r d nothing t o a r o u s e h i s s u s p i -
c i o n s . In t h e r e s u l t - the a i r t r a f f i c c o n t r o l
o f f l c e r w a s u n a w a r e of the m e s s a g e r e c e i v e d
b y t h e S e c u r i t y F o r c e c o n c e r n i n g the a i r c r a f t ' s
take-off, while the SectLon L e a d e r w a s u n a w a r e
t h a t the a i r c r a f t w a s o u t of r a d i o c o m m u n i c a t i o n
with t h e c o n t r o l t o w e r . If t h e i n f o r m a t l o n r e -
c e i v e d by-the S e c u r i t y F o r c e had b e e n i m r n e d i -
a t e l y a v a i l a b l e to the n e r v e c e n t r e of the airport,
c i n i t y of t h e a i r p o r t would h a v e s e t i n m o t i o n
the R e s c u e S e r v i c e s b e f o r e the GCA r e p o r t h a d
b e e n r e c e i v e d and would p r o b a b l y a l s o h a v e
i n h i s i d c n t l f ~ c a t i o nof a "blip" which showed
f o r a v e r y s h o r t time on his r a d a r s c r e e n .
Rescue operations were delayed because
no o n e a t the a i r p o r t r e a l i z e d , o r e v e n s u s p e c t -
e d , the n e e d f o r r e s c u e . A c r a s h w a s n o t
a s s o c i a t e d wlth the l a c k of r a d i o c o m m u n i c a -
tion wholly o r to a l e s s e x t e n t by r e a s o n of the
c u m u l a t i v e e f f e c t a n d m i s l e a d i n g i n f l u e n c e of
the c i r c u m s t a n c e s n e x t m e n t i o n e d a n d c o m -
m e n t e d on:
a ) Any f e a r s e n t e r t a i n e d by the
S e c u r l t y F o r c e f r o m t h e a l a r m given by
the C u s t o m s o f f i c i a l s w e r e a l l a y e d by
t h e a b s e n c e of f l r e , o r a n y o t h e r indi-
c a t i o n of d a n g e r a n d the C u s t o m s officials'
own f e a r s w e r e s e t a t r e s t by t h e l r s e e -
ing no u n u s u a l a c t i v l t y a t the F i r e Station.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
b) The non-observance by the
o f f i c e r on duty i n the a i r traffic control
tower of the a i r c r a f t a f t e r i t ceased t o
climb.
This officer was alone on duty in
the tower. While i t was unfortunate that
he failed to o b s e r v e the a i r c r a f t longer,
when he might have noticed i t s descent,
he cannot be blamed f o r c e a s i n g to watch
i t when he did.
c ) The s e c u r i t y officer on duty in
the F i r e Station Watch Room kept the
flight under observation only until i t p a s s -
ed o v e r the embankment and did not
further see it.
It i s not c l e a r f r o m p a r a g r a p h 1.1
of the Shannon A i r p o r t C r a s h O r d e r s
whether the stand-to period ends when
the departing a i r c r a f t c a n be no longer
s e e n o r h e a r d by the Duty Crew, o r when
i t c a n no longer be s e e n o r h e a r d by the
Look-out. This should be clarified.
The Court accepted the explanation
given by the officer who was in the Watch
Room, that reflections of a i r p o r t lights
on the windows of the Watch Room could
prevent his picking out again the a i r c r a f t ' s
lights when he r e s u m e d h i s watch a f t e r
making h i s log e n t r y .
d ) No d i s t r e s s signal emitted f r o m
the a i r c r a f t .
The c r e w of the a i r c r a f t had no
time to send out a r a d i o d i s t r e s s signal
before ditching and they w e r e unable to
use the radio a f t e r the accident owing to
the lack of e l e c t r i c power and the i m m e r -
sion of the a e r i a l s . P e t r o l on the water
and in the vicinity of the a i r c r a f t and
dinghies precluded the lighting of d i s t r e s s
f l a r e s n e a r the scene of the accident and
no Verey pistol equipment w a s c a r r i e d
in the a i r c r a f t .
e ) The Security F o r c e did not p a s s
on to the control tower the observations
of the Customs o f f i c e r s .
Although there a r e no written
instructions regarding the passing of
suspected flight incident r e p o r t s by the
29
S e c u r i t y F o r c e to the a i r traffic co:ltrol,
i t should be the n o r m a l p r a c t i c e f o r a l l
s u c h r e p o r t s to be p a s s e d to the c o n t r o l
tower s o that any n e c e s s a r y coordination
of action c a n be undertaken by a c e n t r a l
body on the a i r p o r t . The recognition of
the a i r traffic control tower a s the n e r v e
c e n t r e of the a i r p o r t , through i t s knowl-
edge of minute to minute a i r c r a f t move-
m e n t s , should be i m p r e s s e d on a l l
a i r p o r t personnel.
f ) The GCA D i r e c t o r p a s s e d to
a r e a control and tower a r a d a r identifi-
cation of the KLM Constellation in fllght,
outward bound.
The Court c o n s i d e r s that a g r a v e
e r r o r of judgment was committed by the
CCA D i r e c t o r in positively identifying
the a i r c r a f t "blip" a s the KLM Constel-
lation without qualifying the r e p o r t that
the path of the a i r c r a f t had not been
followed f r o m the vicinity of the a i r p o r t
and had, i n fact, only been on the s c r e e n
f o r s o m e ten seconds' duration.
g) F a i l u r e of Launch - Tower Lnter-
communication.
The unfortunate f a i l u r e in obtain-
ing HF/RT communication between the
r e s c u e launch and the control tower when
the launch f i r s t s e t out, c a u s e d by the
tower r e c e i v e r being off tune, r e s u l t e d in
a delay of s o m e 35/40 minutes before the
launch a r r i v e d a t the s c e n e of the d i s a s t e r
It was not considered n e c e s s a r y f o r the
C o u r t to investigate fully the r e a s o n f o r
the r e c e i v e r being off tune but the Court
considered that, a p a r t f r o m the high noise
level in the control tower, the type of
radio installation in use f o r this important
m e a n s of communication, open a s i t i s t o
the possibility of the r e c e i v e r becoming
off tune, c a l l s f o r c r i t i c i s m ,
No blame was attached to e i t h e r the
launch c r e w o r the a i r traffic control
officer In the tower.
Note: The Court was unaware of
any vehicles s u p e r i o r to those p r e s e n t l y
in use a t Shannon f o r negotiating the mud-
f l a t s , but understood that this question is
constantly under review by the a i r p o r t
authorities.
30 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 -
RECOMMENDATIONS , Conslderlng the documents relating t o the
p r e l i m i n a r y investigation made by the P r e l i m -
It i s recommended: i n a r y I n q u i r e r into the c a u s e s of a n accident
which o c c u r r e d to the a i r c r a f t PH-LKY (Triton)
1) That a n a s s i s t a n t to the a i r traffic on September 5, 1954, in the vicinity of Shannon
control officer in the tower a t Shannon A i r p o r t a i r o o r i . Ireland;
be provided a t a l l t i m e s .
Considering the recommendation m a d e by
2) That the stand-to period of the Security the P r e l i m i n a r y Inquirer on October 10, 1955,
F o r c e a t the F i r e Station be m o r e c l e a r l y de- No. BVO-3/8, to the effect that no f u r t h e r in-
fined in the Shannon A i r p o r t C r a s h O r d e r s . vestigation will be m a d e by the Aeronautical
Council;
3) That instructions be i s s u e d to a l l s e c - Taking into account that the Commission
tions and s e r v i c e s employed a t the a i r p o r t to
communicate suspected flight a b n o r m a l i t i e s to f r o m the documents pertaining to the p r e l i m -
the a i r traffic control tower and that the i m - i n a r y investigation found the following:
portance of this r e q u i r e m e n t be s t r e s s e d .
a ) P r o g r e s s of the flj qht.
4 ) That CCA c r e w s be instructed not to Although the a i r c r a f t was heavily
r e p o r t identifications of a i r c r a f t to o t h e r loaded, the take-off weight was approximately
agencies without giving a p p r o p r i a t e identifying 500 kgs below the m a x i m u m take-off weight.
facts. The a i r c r a f t was airworthy. With the excep-
tion of a few p a r t s to which r e f e r e n c e will be
5) That the noise level i n the control m a d e below, the inspection of the wreck show-
tower be reduced to a minimum, while a t the ed no evidence of technical deficiencies. The
s a m e t i m e adequately monitoring r e q u i r e d r a d i o engines functioned normallv
frequencies.
The Commission i s in a g r e e m e n t with
6 ) That radio communication installa- a reconstruction of the take-off path p r e p a r e d
tions fitted to the r e s c u e launches, o r any other by the I r i s h C o u r t of Inquiry.
a i r p o r t s e r v i c e equipment be s u c h that effective
instantaneous inter-communication i s e n s u r e d During the f i r s t 25 seconds a r t e r leaving
a t all times. the ground the c l i m b was normal. During t h i s
period take-off power w a s reduced to M E T 0
- Note: The Court was gratified to l e a r n
of the work in p r o g r e s s ( p r i o r to 5 September
power ( m a x i m u m except take-off power] a f t e r
approximately 15 to 20 seconds. At the end of
1954) f o r construction of a R e s c u e Launch this period a height was r e a c h e d of approximak-
Station a t the a i r p o r t . When this work i s com- ly 40 m e t r e s . At that moment the captain
pleted, a launch will be m o r e readily available c o n s i d e r e d the u n d e r c a r r i a g e to be fully r e -
f o r emergency. t r a c t e d , and he gave the o r d e r to r e t r a c t the
wing flaps which a t the time w e r e i n the take-
Subject to this, the r e s c u e facilities and off position. During this manoeuvre the take-
s e r v i c e s a t Shannon A i r p o r t w e r e considered off condition began to develop unfavourably.
adequate and no recommendation was made in After the a i r c r a f t had reached a height of 50
this r e g a r d . m e t r e s (according to the indication of the alti-
m e t e r 80 m e t r e s ) , the flight path gradually
changed f r o m a c l i m b into a descent. The de-
Comments of the Netherlands Government s c e n t continued during the l a t e r p a r t of the
on the I r i s h Report flight, f o r a period of approximately 10 seconds.

The descent could have been a p p a r e n t to

"Aeronautical Council the captain f r o m the indications of various in-
The Hague -
The Netherlands. s t r u m e n t s , in p a r t i c u l a r f r o m the indications
of the a r t i f i c i a l horizon and the a l t i m e t e r . A
DECISION few m o m e n t s l a t e r this descent would a l s o have
The Commission formed f r o m the "Aero- been apparent f r o m the indication of the vertical
nautical Councilf1r e f e r r e d to in A r t i c l e 6 of the speed indicator which r e a c t s with a c e r t a i n delay.
"Act, regulating the Investigation of Accidents However, the captain pald insufficient attention
to Clvil A ~ r c r a f t ; " to these i n s t r u m e n t s slnce he was of the opinion
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
that with a n o r m a l l y functioning a i r c r a f t no spe-
c i a l a l e r t n e s s in r e s p e c t of the continuation of
the take-off w a s required a f t e r reaching a height
of approximately 75 m e t r e s .
A s soon a s the flaps w e r e fully r e t r a c t e d
he gave the o r d e r to reduce the power of the
engines to c l i m b power without f i r s t reading the
a l t i m e t e r . This m u s t have taken place approxi-
mately f o u r seconds before the a i r c r a f t c a m e
into contact with the water. A few seconds l a t e r
the captain r e a l i z e d that the a i r c r a f t was de-
scending. He took action with the elevator
control. Due to the s m a l l distance between the
a i r c r a f t and the water the only favourable r e s u l t
of this action w a s that upon contact with the
w a t e r a heavy impact was avoided,
b) After considering this c o u r s e of events
the Commission a g r e e s with the conclusions of
the I r i s h Court that, in the f i r s t place, the acci-
dent m u s t be attributed to the captain failing to
pay sufficient attention to the indications of the
i n s t r u m e n t s , in p a r t i c u l a r those of the a r t i f i c i a l
horizon and the a l t i m e t e r .
Some attending c i r c u m s t a n c e s , which
contributed to the accident were:
1. P r i o r to take-off the captain failed
to adjust the a l t i m e t e r according to the
l a t e s t b a r o m e t r i c p r e s s u r e communicated
to him; a s a r e s u l t the a l t i m e t e r o v e r r e a d
by cix m e t r e s .
2. In addition, i n s t r u m e n t e r r o r s of
the a l t i m e t e r and the change of barometric
p r e s s u r e , which o c c u r r e d a f t e r the l a s t
weather r e p o r t communicated to the a i r -
c r a f t , r e s u l t e d in a n o v e r r e a d i n g of 20 to
25 m e t r e s ,
3, In a l l probability the warning light,
which should be on when the undercarriage
i s not r e t r a c t e d and locked, was unserv-
iceable. This may have led the captain to
the conclusion that the u n d e r c a r r i a g e was
r e t r a c t e d and locked while this was actual-
ly not the c a s e . Investigation of the wreck
revealed L I L ~ LLhe ,lose wneel and the s t a r -
board main g e a r could not have been lock-
ed up. If the u n d e r c a r r i a g e is not locked
in the position, r e t r a c t i o n of the
31
wing f l a p s m a y r e s u l t in the landing g e a r
moving down again. The resulting in-
c r e a s e in d r a g considerably affects the
c l i m b p e r f o r m a n c e of the a i r c r a f t . When
M E T 0 power is applied, s u c h need not
n e c e s s a r i l y r e s u l t in a descent. How-
e v e r , when insufficient attention i s paid
to the indications of the i n s t r u m e n t s the
flight path m a y e a s i l y change f r o m a
c l i m b lnto a descent. T h i s possibility i s
f u r t h e r enhanced by an apparent tendency
to pay m o r e attention to the i n c r e a s e i n
speed than to the maintaining of a suffi-
cient r a t e of c l i m b (shallow take-off).
Consequently, a s a r e s u l t of the
dnserviceability of the warning light the
captain did not r e a l i z e that the condition
of the a i r c r a f t had become such that the
climb p e r f o r m a n c e was unfavourably
affected. This again r e s u l t e d in the f a c t
that the actions which the captaln nor-
mally took during take-off did not lead
to a n o r m a l continuation of the climb.
The consideration which prompted
the Commission to view the above f a c t o r
a s only a secondary c a u s e of the accident
i s that during a night take-off the captain
should pay considerable attention to the
indication of the i n s t r u m e n t s . If the cap-
tain had paid this attention, he would have
been able to take the n e c e s s a r y action in
time.
4. That a dangerous situation should
a r i s e i s a l s o to be attributed to the tempo
in which the v a r i o u s actions followed e a c h
o t h e r , such a s the r e t r a c t i o n of the under-
c a r r i a g e , power reduction to M E T 0 power,
flap r e t r a c t i o n , and power reduction to
c l i m b power. As a r e s u l t the captain did
not fully utilize the favourable p e r f o r m a n c e
possibilities of the a i r c r a f t , and t h e r e b y
it happened that, a s explained under 3 , the
flap r e t r a c t i n g s y s t e m s t a r t e d to o p e r a t e
before the u n d e r c a r r i a g e was locked.
Take-off power had only been applied
f o r approximately 50 seconds, w h e r e a s
2 minutes' continuous take-off power i s
allowed without affecting the p r o p e r func-
tioning of the engines.
32 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
M E T 0 power had only been applied
during approximately 25 seconds, where-
a s t h e r e i s no r e s t r i c t i o n a s to the d u r a -
tion of this power setting. With wing
f l a p s r e t r a c t e d the c l i m b p e r f o r m a n c e of
the a i r c r a f t e x c e e d s the c l i m b p e r f o r m -
a n c e with f l a p s in the take-off position
only by a v e r y s m a l l m a r g i n . T h e r e f o r e ,
e a r l y r e t r a c t i o n of the f l a p s i s not a t a l l
necessary.
This f a s t tempo of s u c c e s s i v e
a c t i o n s , together with the a p p a r e n t tend-
ency to pay m o r e attention to the i n c r e a s e
of speed than to the maintenance of a suf-
ficient r a t e of climb, contributed to the
beginning of the descent.
In the c a s e under review the take-
off p r o c e d u r e i s incompatible with the
r e q u i r e m e n t s of safe a i r traffic. 111 this
connection it may be o b s e r v e d that the
c r e w was under the e r r o n e o u s i m p r e s s i o n
that ~t would be beneficial to the reliability
of the engines if the time during which
take-off power i s applied w e r e to be r e -
duced to a minimum.
c ) L e s s o n s to be d e r i v e d f r o m t h e a c c i -
-
dent.
1. When flying with reduced o r z e r o
visibility, o r in d a r k n e s s close to the
ground, much attention h a s to be paid to
i n s t r u m e n t s which give information on
the v e r t i c a l movements of the a i r c r a f t .
2. A f a s t tempo i n which during take-
off the various actions in relation to
engine-, u n d e r c a r r i a g e - and f l a p han-
dling a r e c a r r i e d out, together with the
application of a shallow take-off, reduce
the safety m a r g i n which i s e s s e n t i a l i n
view of unforeseen c i r c u m s t a n c e s . The
r e l a t i v e KLM instructions p e r m i t t e d
application of a take-off p r o c e d u r e , the
safety a s p e c t s of which left r o o m f o r
improvement. KLM h a s d e r i v e d f r o m
this accident, a s well a s f r o m a n a c c i -
dent which happened a s h o r t time p r e -
viously, the l e s s o n that the take-off
iCAO R e f : AK ' $ 5 1
p r o c e d u r e for i t s a i r c r a f t h a d to he de-
s c r i b e d in m o r e detail. Revised i n s t r u c -
tions have been i s s u e d to i t s flying p e r -
sonnel.
3. One of the recommendations made
by the I r i s h C o u r t of Inquiry was to
duplicate the u n d e r c a r r i a g e warning
lights. Follow-up action h a s been taken.
d) Consideration of the need of a f u r t h e r
inquiry.
T h e P r e l i m i n a r y Inquirer proposed not to
hold a f u r t h e r inquiry. A v e r y a c c u r a t e and
competent investigation was m a d e by the I r i s h
C o u r t of Inqulry, the r e s u l t of which, together
wilh a l l relevant documentation, was kindly put
a t the d i s p o s a l of the D e p a r t m e n t of Civil Avia-
tion and the Aeronautical Council. The F r e -
l i m i n a r y I n q u i r e r c o n c u r s with the viewpoints
a n d the resulting v e r d i c t , which i s a l s o e n t i r e l y
acceptable to the above mentioned Commission.
Under the c i r c u m s t a n c e s taking of disciplinary
action a g a i n s t the captain i s not urgently r e -
q u i r e d , and i t i s the t a s k of the c o m m i s s i o n
to d e c l a r e that a f u r t h e r investigation need not
be held.
According to the I r i s h C o u r t , i t i s evident
that, by neglecting the indications of the i n s t r u -
m e n t s , the captain failed to e x e r c i s e caution.
However, taking into c o n s i d e r a t i o n the d i s t r e s s
which the accident h a s caused to the captain and
a l s o taking into consideration the f a c t that this
accident brought the v e r y long and distinguished
c a r e e r of the captain to a n end, the C o m m i s s i o n
c o n s i d e r s it justifiable that, in this c a s e , the
Council d o e s not e x e r c i s e i t s a u t h o r i t y to take
the d i s c i p l i n a r y action r e f e r r e d to in a r t i c l e 3 7
of the Act regulating the investigation of Acci-
d e n t s to Civil A i r c r a f t .
B a s e d on the above c o n s i d e r a t i o n s , the
C o m m i s s i o n h a s decided that no f u r t h e r inquiry
will be held by the Aeronautical Council into the
c a u s e s of the accident. l 1
dated Y J a n u a r y 1 9 5 6
 -
KIM Lockheed Super Ccmtellatmn crnsl~ River Shpmwm. lrrknd - 5 September 1954

Haghr FT

200 -
"SHADOW ARIA. FROM FIRE
MAX 260 FT STATION FOR OBSERVER ON
APRON AT CUSTOMS+WATCH-
ROOM SHOWN THUS-

100 -
PROPELLERS No. 3 AND 4

6000 6000 7000 8000 9300 10000 11000 12000 13000

I
1 -
WREK

14000 FT.
DISTANCE FROM THRESHOLD FT.

5 10 15 20 25 30 35 40 SECS.
TIME FROM UNSnCK : SEC.

FIGURE 1
FLIGHT PATH AND
RELATED INSTRUMENT
INDICATIONS
 htch angle KLM Lockheed Super Consellation crash - River Shaunm, Ireland - 5 September 1954
(PEA)
hor. bar. mm.
belarned

RATE OF CLIMB
4 ENGINESm o POWER
(Doc 204 AND 255)

FIGURE 2
TIME HISTORY
AND
INSTRUMENT INDICATIONS
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
No. 4
N n t i n n a l A i r l i n e s . Tnr. . 1,nrkheed 1 , o d e s t a r . P i n e l l a s C,ountv rnternational
Circumstances
T h e flight o r i g i n a t e d a t Orlando, F l o r i d a ,
destination Miami with i n t e r m e d i a t e s t o p s a t
Lakeland, T a m p a , St. P e t e r s b u r g , S a r a s o t a ,
F o r t M e y e r s and West P a l m Beach. T h e a i r -
c r a f t d e p a r t e d Orlando a t 0805 h o u r s E a s t e r n
S t a n d a r d T i m e with 10 p a s s e n g e r s and 3 c r e w .
T h e flight was r o u t i n e up t o take-off t i m e a t
St. ~ e t e r s b u r ~T.h e captain taxied t h e a i r c r a f t
t o t h e run-up position for Runway 9 and then
t u r n e d t h e a i r c r a f t o v e r t o t h e co-pilot. As
the a i r c r a f t p r o g r e s s e d down the runway i t
s w e r v e d s e v e r a l t i m e s , t h e landing g e a r col-
l a p s e d r u p t u r i n g a fuel tank, and t h e a i r c r a f t
c a m e to r e s t on t h e sodded a r e a off t h e runway.
F i r e b r o k e out i m m e d i a t e l y . Two c r e w m e m -
b e r s received minor injuries.
Investigation and Evidence
After a n o r m a l run-up t h e co-pilot taxied
t h e a i r c r a f t to t h e end of the 5 010 foot runway.
The a i r c r a f t was then lined up with t h e runway
slightly to he r i g h t of t h e c e n t e r l i n e , t h e t a i l
wheel was locked, a n d power was applied. As
t h e a i r c r a f t p r o g r e s s e d down the runway t h e
t a i l c a m e up a n d t h e co-pilot applied f o r w a r d
p r e s s u r e t o the c o n t r o l colrimn. Shortly t h e r e -
a f t e r t h e a i r c r a f t began t o s w e r v e to t h e l e f t
and when t h i s w a s c o r r e c t e d i t went too f a r to
t h e right. A s e r i e s of o v e r - c o r r e c t i o n s fol-
lowed which r e s u l t e d i n s e v e r a l s w e r v e s in both
d i r e c t i o n s . As t h e s e m a n o e u v r e s began t h e
c r e w noted a five-inch d r o p i n the manifold
p r e s s u r e of t h e l e f t engine. At a s p e e d of ap-
p r o x i m a t e l y 80 knots t h e a i r c r a f t again began
turning to the left. T h e captain i m m e d i a t e l y
took o v e r the c o n t r o l s when he noticed a second
d r o p of 25 i n c h e s i n manifold p r e s s u r e of the
s a m e engine. Both t h r o t t l e s w e r e c l o s e d a t
o n c e and he t r i e d u n s u c c e s s f u l l y t o stop t h e
t u r n . T h e t u r n developed into a s k i d and the
m a i n landing g e a r collapsed r u p t u r i n g the right
fuel tank.
The captain and co-pilot s t a t e d that soon
a f t e r t h e t h r o t t l e s w e r e advanced f o r both en-
gines t o t h e p r e s c r i b e d 45-1/2 i n c h e s of m a n i -
fold p r e s s u r e , a d r o p of 4 to 5 inches was
- 35
o b s e r v e d on t h e l e f t manifold p r e s s u r e gauge.
T h e left t h r o t t l e w a s f u r t h e r advanced a n d t h i s
w a s followed by a second d r o p i n manifold
p r e s s u r e t o 20-25 i n c h e s . According t o t h e
pilots, each d r o p in manifold p r e s s u r e w a s
accomparlied by a yaw t o t h e left.
The captain t e s t i f i e d t h a t he applied f u l l
r i g h t b r a k e and r u d d e r i n a n a t t e m p t to s t o p
the l e f t t u r n . T h i s was u n s u c c e s s f u l and h e
then " s t o o d l ~on both b r a k e p e d a l s i n a n e f f o r t
to s t o p the a i r c r a f t , l'ht- co-pilot t e s t i f i e d
t h a t he did not u s e t h e b r a k e s during the t a h e -
off r u n .
T h e flight c r e w s a i d that a t no t i m e did
the a i r c r a f t t u r n t o t h e right a f t e r t h e take-off
s t a r t was m a d e f r o m a position lined up on t h e
runway. However, t h e s t e w a r d e s s t e s t i f i e d
t h a t t h e r e was a s w e r v e to t h e r i g h t , then t o
t h e left, again t 3 t h e r i g h t , followed by a con-
tinuous l e f t t u r n off t h e runway. One p a s s e n g e r ,
with a i r c r a f t p i l o t ~ n ge x p e r i e n c e , a l s o s a i d
that t h e a i r c r a f t "fisht,ailed" o r m a d e definite
s w e r v e s both right and l e f t p r i o r t o t h e s t a r t
of t h e continuous l e f t t u r n .
T h e cockpit was i n t h e a r e a of heavy f i r e
d a m a g e and instrume,.ts, ~ e d e s t a l sand e l e c -
t r i c a l panels w e r e d.estroyed. All c a b l e s
coming out of the yoke w e r e b u r n e d off. Ex-
cept f o r s t e e l p a r t s t h e r i g h t engine w a s d e r
s t r o y e d by f i r e . T h e b r a k e d i s c s showed no
evidence of having malfunctioned.
On Lockheed L o d e s t a r s t h e m e t h o d of
changing t h e f o r e and a f t position of t h e r u d d e r
and b r a k e pedals i s by m a n u a l d d ~ ~ ~ t mof ent
t h e hanger a r m supporting t h e ~ e d a l s . T h e
c h a r a c t e r i s t i c s of the r u d d e r ~ e d a al d j u s t m e n t
m e c h a n i s m a r e s u c h that a t t e m p t s t o p l a c e t h e
p e d a l in t h e f a r t h e s t f o r w a r d position can r e s u l t
i n t h e projecting tooth on t h e a d j u s t m e n t pawl
passing beyond t h e end of the r a t c h e t r a t h e r
than engaging i n the l a s t r e c e s s of t h e r a t c h e t .
When this o c c u r s , t h e pedal, on c a s u a l i n s p e c -
tion, a p p e a r s to be p r o p e r l y a d j u s t e d and t h e
r u d d e r and b r a k e s y s t e m s a r e o p e r a t i v e . HOW-
e v e r , in rhis condition pedal l o a d s a r e t r a n s -
rrlittcd t o tlle pedal dSs"nlbly torclue tube through
36 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
rrlating o f f s e t s on t h e r u d d e r pedal hanger and
tlie t o r q u e a r m a t t h e i r a t t a c h m e n t to t h e t o r q u e
tube. When r e l a t i v e l y high pedal l o a d s a r e
applied the a l u m i n u m alloy casting a t the off-
s e t of the pedal a r m m a y t e a r out causing t h e
l o s s of r u d d e r and b r a k e c o n t r o l due to t h e
pedal hanger swinging f o r w a r d .
With r e f e r e n c e to t h e s u b j e c t accident,
during t h e investigation t h e captain s t a t e d t h a t
his pedals w e r e Ifforward" a t t h e t i m e of
leaving t h e t e r m i n a l , F i r e d e s t r o y e d t h e
r u d d e r m e c h a n i s m and i t was, t h e r e f o r e , i m -
possible to d e t e r m i n e the exact position t h e
r u d d e r pedals w e r e in p r i o r t o the a c c i d e n t ,
o r if a f a i l u r e had o c c u r r e d .
T h e L o d e s t a r a i r c r a f t h a s c e r t a i n ground
c h a r a c t e r i s t i c s which r e q u i r e t h e pilot t o u s e
e x t r a c a r e to m a i n t a i n d i r e c t i o n a l c o n t r o l
during the e a r l y s t a g e s of t h e take-off run.
C o n s i d e r i n g this f a c t , together with t h e co-
pilot's previous flying e x p e r i e n c e both b e f o r e
dnd a f t e r h i s erilployment by t h e c a r r i e r , i t
i s obvious that the captain should have been
e x t r e m e l y o b s e r v a n t of t h e co-pilot's tech-
nique. T h e co-pilot had been a c c u s t o m e d t o
flying l a r g e a i r c r a f t with t r i c y c l e g e a r which
w e r e not in the l e a s t s u s c e p t i b l e to t h e s e pe-
c u l i a r ground c h a r a c t e r i s t i c s .
'There i s no doubt that during the i n i t i a l
s t a g e s of the take-off r u n t h e co-pilot o v e r -
ont trolled t h e a i r c r a f t i n an e f f o r t t o keep
s t r a i g h t on t h e runway. T h e s e o s c i l l a t i o n s
Loth to the left and right w e r e m a d e until t h e
a i r c r a f t went i n t o a s e v e r e left t u r n . T h e
f o r w a r d s p e e d of t h e a i r c r a f t m a d e i t light on
i t s wheels and n e a r l y r e a d y to t a k e off, making
b r a k i n g action l e s s effective. T h e captain then
b e c a m e a l a r m e d and took o v e r . T h i s action
of the captain was e i t h e r too l a t e o r a f a i l u r e
o c c u r r e d which prevented h i m f r o m being a b l e
t o control the a i r c r a f t effectively. In t h i s
r e s p c c t i t 1s possible that during the c a p t a i n ' s
efforts to s t o p t h e a i r c r a f t h e e x e r t e d suffi-
cient pedal p r e s s u r e to b r e a k t h e o f f s e t s of
the t o r q u e a r m thus preventing braking and
r u d d e r action. Since f i r e d e s t r o y e d t h e pedal
m e c h a n i s m , t h i s could not be d e t e r m i n e d .
Although both the c a p t a i n and co-pilot
s t a t e d that the left engine l o s t power momen-
t a r i l y during t h e take-off, inspection and t e s t
of the engine failed to duplicate t h i s malfunc-
tion. Since t h i s engine was found t o function
i n a n o r m a l m a n n e r , t h e d r o p i n manifold
p r e s s u r e was not r e p e t i t i v e .
-
T h e r e i s no evidence indicating that
s t t u c t u r a l f a i l u r e o r malfunction of c o n t r o l s
o c c u r r e d . However, t h e r e e x i s t s t h e inde-
t e r m i n a b l e possibility that during t h e take-
off r u n t h e r e was a f a i l u r e of t h e pedal a s -
sembly.
Probable Cause
T h e p r o b a b l e c a u s e of t h i s accident w a s
t h e co-pilot's l o s s of d i r e c t i o n a l c o n t r o l d u r i n g
t h e take-off r u n and t h e inability of t h e captain
t o r e g a i n c o n t r o l of t h e a i r c r a f t , the l a t t e r
possibly due t o f a i l u r e of t h e pedal m e c h a n i s m .
F i r e A s p e c t s ( f r o m NFPA Special A i r c r a f t
Accident Bulletin, S e r i e s 1955: No. 5)
While t h e f i r e o r i g i n a t e d n e a r the right
engine n a c e l l e , i t w a s n e e d l e s s l y allowed t o
do e x t e n s i v e d a m a g e which s e r i o u s l y compli-
c a t e d investigation into t h e a c t u a l c a u s e of t h e
accident and d e s t r o y e d m o r e p r o p e r t y than
was n e c e s s a r y .
T h e s t o r y of t h e mishandling of t h e f i r e
should be told s o that s i m i l a r s e q u e n c e s will
not o c c u r .
9:38 A i r c r a f t groundlooped, g e a r col-
l a p s e d and f i r e s t a r t e d i n a r e a of
r i g h t engine n a c e l l e .
9:38t Under s u p e r v i s i o n of s t e w a r d e s s ,
all passengers left the a i r c r a f t in
a r a p i d o r d e r l y m a n n e r through
t h e m a i n cabin door ( l e f t side).
T h e pilots m a d e e g r e s s t h r o u g h
cockpit windows. A l a r m given t o
A i r p o r t F i r e D e p a r t m e n t by T o w e r
Controller.
9:40 Airport F i r e Department reached
t h e s c e n e with a c r a s h t r u c k ( c a p a c -
i t y 250 gallons of p r e m i x e d f o a m )
and two 30 lb. d r y c h e m i c a l extin-
g u i s h e r s . F i r e c o n t r o l could not
be achieved with t h i s equipment.
9:46 Telephone c a l l r e c e i v e d by
St. P e t e r s b u r g F i r e D e p a r t m e n t .
9:46+ St. P e t e r s b u r g F i r e D e p a r t m e n t
a n s w e r e d c a l l with t h r e e t a n k
wagons and one p u m p e r . On a r -
r i v a l , they w e r e told "to l e t the
plane burn" a s a l l p a s s e n g e r s had
been r e m o v e d and t h e plane was
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
"fairly well consumed by f i r e f 1 .
No attempt was made by the
St. P e t e r s b u r g F i r e Department
to extinguish the f i r e and a l l equip-
ment was r e t u r n e d to the station.
10:05 U. S. Coast Guard Air Station a t
St. P e t e r s b u r g received telephone
call f r o m St. P e t e r s b u r g F i r e
Department that the a i r c r a f t had
crashed. F i r e t r u c k with c r e w
was dispatched immediately.
10:lO U.S. Coast Guard Duty Officer
advised by Pinellas Tower that
f i r e was out and t r u c k would not
ICAO R e f : A R / 3 8 4
37
be needed. Police Department
called and f i r e t r u c k was stopped
by t h e m and told to r e t u r n to base.
10:25 P i n e l l a s Tower advised U. S.
Coast Guard that f i r e had s t a r t e d
again. F i r e t r u c k and c r e w w e r e
again dispatched.
10:45 U.S. Coast Guard f o a m t r u c k a r -
rived a t s c e n e of c r a s h with 10
m e n (distance: 18 miles).
10:50 F i r e extinguished by f o a m (100
gallons of f o a m liquid and 1 000
gallons of water).
T r r e o r t g x x u w t ~ drn rrght wrng of 1,oilkheed Lodestar after gear collapse faiiawrng i s s s ol control an
l a k e - o f t from Panellas County Inlerraat~onalAsrporC, St, Petersburg, FXorrda, 031 b 0 Jmruary 1955,
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 39

No. 5

T r a n s - W o r l d A i r l i n e s I n c . , M a r t i n 202-A and Castleton, Inc., Douglas DC-3C,

.
collided n e a r G r e a t e r Cincinnati Airoort.- Ohio. on 12 J a n u a r v 1955. Civil
Aeronautics B o a r d IU. S. A. 1 Accident Investieation Report No. 1-0014.
V

r e l e a s e d 8 Julv 1955

Circumstances wreckage t o indicate any malfunction o r f a i l u r e

T h e DC-3 a i r c r a f t departed Battle C r e e k ,
Michigan, a t approximately 0733 h o u r s en
r o u t e to Lexington, Kentucky, and thence t o
Miami, F l o r i d a , c a r r y i n g two pilots. T h e
flight was proceeding i n a c c o r d a n c e with
Visual Flight Rules t o Lexington and if t h e
weather lowered en route the pilot planned to
f i l e in flight f o r a n I F R c l e a r a n c e . However,
n o plan was filed before d e p a r t u r e o r i n the
a i r , nor w e r e r a d i o f a c i l i t i e s along t h e r o u t e
contacted by the pilot. T h e Martin 202-A
departed G r e a t e r Cincinnati A i r p o r t a t 0902
h o u r s E a s t e r n Standard T i m e on a n I n s t r u m e n t
Flight Rules flight plan t o Cleveland, Ohio,
with 13 p e r s o n s aboard. While making a r i g h t
t u r n a f t e r take-off f r o m Runway 22, t h e M a r t i n
202-A collided with t h e DC-3 about 2-1/2 m i l e s
west of the G r e a t e r Cincinnati A i r p o r t , in t h e
control zone*, a t 0904 h o u r s . Both a i r c r a f t
went into s t e e p dives, s t r u c k the ground, kill-
ing a l l occupants, and w e r e demolished a s a
r e s u l t of collision, ground i m p a c t and f i r e .
Investigation and Evidence
p r i o r to the collision.
The DC-3 s t r u c k the ground i n a s t e e p dive
(on t h e s t u b of the l e f t wing, t h e n o s e section
and engines) one m i l e south of t h e Martin, ap-
proximately 2- 1/4 m i l e s west-southwest of t h e
control t o w e r , A number of b a t t e r e d and t o r n
s e c t i o n s of the left wing outboard of t h e f l a p
and portions of t h e v e r t i c a l tail w e r e t o r n off
a t the t i m e of collision. T h e cockpit w a s de-
molished. F o u r p r o p e l l e r c u t s w e r e found
a c r o s s the top of the fuselage, two in t h e v e r -
t i c a l tail, and one i n t h e left wing. T h e fin w a s
badly c r u s h e d a n d torn, and the r u d d e r was
detached a t the hinges. T h e landing g e a r was
r e t r a c t e d . The f l a p m e c h a n i s m was d e s t r o y e d
and, t h e r e f o r e , the position of the f l a p s a t
i m p a c t could not b e a s c e r t a i n e d . Examinatio n
of the p r o p e l l e r dome a s s e m b l i e s r e v e a l e d that
the pitch on t h e left p r o p e l l e r a t ground i m p a c t
was 41 d e g r e e s , and the right 39 d e g r e e s . All
r a d i o equipment was s o s e v e r e l y damaged that
i t was i m p o s s i b l e t o a s c e r t a i n with any c e r t a i n t y
what, i f any, equipment was i n u s e , o r to which
frequency i t might have been tuned.

Examination of the Martin wreckage Study of the wreckage of both a i r c r a f t d i s -

(2-1/2 m i l e s west of the a i r p o r t control tower
a n d approximately the s a m e distance f r o m the
southwest end of Runway 22) showed that the
right wing was p a r t i a l l y s e v e r e d chordwise a t
collision about 22 f e e t f r o m the c e n t e r line of
the fuselage, and wrenched off while the a i r -
c r a f t was s t i l l i n the a i r . Due to striking the
ground i n a f a i r l y s t e e p dive the cockpit and
i t s components disintegrated to such a d e g r e e
that no information was obtainable on the posi-
tion of cockpit c o n t r o l s and r a d i o equipment.
It was a s c e r t a i n e d that both the landing g e a r
and the flaps w e r e r e t r a c t e d when the a i r c r a f t
s t r u c k the ground. Inspection of the p r o p e l l e r
d o m e s showed that the pitch of the p r o p e l l e r
blades a t ground i m p a c t was 47 d e g r e e s . No
evidence was disclosed in examination of the
closed that i m m e d i a t e l y p r i o r t o i m p a c t the a i r -
c r a f t approached each o t h e r a t an angle of about
30 d e g r e e s f r o m head on, with the longitudinal
axis of the two a i r c r a f t c r o s s i n g to the left of
the Martin and to the right of t h e DC-3. T h e
a i r c r a f t w e r e banked r e l a t i v e t o one another s o
that the left wing of the M a r t i n was higher than
the right wing of the DC-3, while t h e r i g h t o u t e r
wing of the Martin and the left o u t e r wing of t h e
DC-3 w e r e i n position to collide. In addition,
the collision d a m a g e i n d i c a t e s that the M a r t i n
was climbing r e l a t i v e t o the DC-3.
T h e f i r s t m a j o r components t o c o m e in
contact w e r e the left wing of t h e DC-3 and the
right p r o p e l l e r of the Martin. T h e right wing
of the Martin a n d the left wing of t h e o t h e r

* A control zone i s an a i r s p a c e of defined d i m ?n s i o n s , extending upward f r o m the s u r f a c e , t o

include one o r m o r e a i r p o r t s .
40 ICAO Circular 5 0 ~ ~ N / 4 5 ,
aircraft then struck, resulting in disintegra-
tion of the DC-3 wing in the contact area, and
causing such structural damage to the Martin
right wing that i t separated from the aircraft
before ground impact. While the two wings
were tearing through one another, the left pro-
peller of the Martin started i t s cuts across
the top of the DC-3 fuselage and through the
vertical fin and rudder while the Martin moved
across and to the r e a r of the other aircraft,
Near the end of the contact period, the inboard
side of the Martin left nacelle inflicted severe
crushing damage on the DC-3 vertical tail,
causing portions of the DC-3 fin and rudder
to separate in flight.
Several witnesses were found who saw or
heard the two aircraft after collision. Witness
No. l* heard the Martin take off. About two
or three minutes later he heard a sharp sound
to the southeast which resembled a clap of
thunder or blasting. Directing his attention
toward the source of this unusual sound, he
saw nothing except the low overcast for an
appreciable time, testifying that i t might have
been a s long a s 30 seconds before he saw an
aircraft (Martin 202-A) dive out of the clouds
and burst into a ball of flame when i t struck
the ground. At no time did this witness see
or hear the DC-3.
Witness No. 2 heard an explosion while at
home. Looking out of his west window he saw
an aircraft (Martin 202-A) headed north. For
an instant it appeared to be in level flight near
the base of the clouds, then went out of control,
dived to the ground at about a 45-degree angle,
and exploded upon impact.
Witness No, 3 "heard a loud noisell. Look-
ing up, he saw two aircraft to the northwest,
just under the base of the overcast. The DC-3
was in a steep dive and the Martin was appar-
ently trying to pull out of a dive. Although thia
.witness lived near the end of Runway 22, he
did not recall hearing the Martin take-off.
Witness No. 4, a teacher in a school about
a mile and a half north of the site of the inter-
mingled wreckage, testified that she heard an
aircraft west of her position, flying south,
shortly before the time of the collision.
* Position denoted on Figure 4 by numeral 1; 0th er witness positions a r e similarly noted by
appropriate numbers.
One of the students (Witness No. 5) tes-
tified that he heard an aircraft and on looking
out of the window he saw it pass the end of the
building, going west, and i t appeared, to be
flying close to the base of the clouds. His
attention was again drawn to the aircraft a
few moments later, when he heard a roar of
engines, looked up, and almost at the same
instant saw an explosion in the a i r , accom-
panied by a mushroom of smoke. He said
that he saw "two tails" and the wreckage
"came down i n one heapu.
Witness No. 6 who lived near the school-
house, heard am aircraft take off from the air-
port. He then heard an aircraft coming from
the north and it passed, going south, west of
where he was standing. It seemed to him from
the sound that this second aircraft was very
low. He searched the sky but never saw either
of the two aircraft apparently because of the
"hazy conditionn. On searching the sky he
heard a thud and an explosion, followed by a
surge of engines from one of the aircraft,
Witness No. 7 was in west Cincinnati when
at about 0855 his attention was drawn to an
aircraft flying much lower than usual, which
he definitely identified a s a DC-3. It continued
past his position, flying in a southwesterly
direction, disappearing and reappearing in the
overcast several times.
The presence of the DC-3 in the control
a r e a was unknown to CAA Air Route Traffic
Control 'and the Cincinnati tower. Civil A i r
Regulations specify that aircraft shall not be
flown within a control zone beneath the ceiling
when it i s less than 1 000 feet, unless author-
ized by air traffic control. If operating on an
IFR clearance, a flight would already be under
the jurisdiction of air traffic control for flight
within a control zone; if on a VFR flight plan,
or no flight plan, a clearance t o operate within
the control zone would have to be requested i f
weather conditions were IFR (ceiling l e s s than
1 000 feet or visibility l e s s than 3 miles). If
the ceiling i s l e s s than 1 000 feet, an aircraft,
if cleared, may operate within the zone, re-
maining underneath and clear of clouds. In
this instance, the ceiling was l e s s than 1 000
feet and no request was receiyed from the
 ICAO Circular 5 0 - ~ N / 4 5
DC-3 for a clearance to operate within the
control zone.
The weather reports reviewed by the
captain of the DC-3 before departure f r o m
Battle Creek showed the elcistence of an over-
c a s t over the entire route, ceilings lowering
f r o m 3 100 feet a t point of departure a r e a to
1 300 feet a t Lexington, visibility lowering
f r o m 8 miles a t departure point to 2 miles a t
Lexington, precipitation throughout, icing in
the clouds and precipitation a r e a s , and below
freezing temperatures existing over the entire
route f r o m the surface upwards. Since the
flight was conducted without flight plan, in
weather conditions which became poorer, and
without communicating with any station en
route, i t i s considered that the captain failed
to exercise reasonable judgment and conducted
this operation contrary to good operating prac-
tices. In the light of the weather situation the
flight should have been planned and conducted
so a s to avoid flying a t low altitudes i n m a r -
ginal VFR conditions.
At 0907 (3 minutes after the accident) the
U. S. Weather Bureau reported the folldwing
conditions: ceiling 800 feet variable; over-
cast; visibility 4 miles; light freezing drizzle;
fog (extending f r o m ground to overcast); tem-
perature 28; dewpoint 25; wind southwest 11
knots; altimeter setting 29.99 inches. Re-
m a r k s - ceiling 700 feet variable to 900 feet.
cloud cover between 3 000 to 4 000 feet thick.
It appears that in the collision a r e a ,
visual reference to the ground was possible
up to 900 feet above the surface. It also
appears highly probable that visibility pro-
gressively decreased with altitude, and that
near the cloud base i t was considerably l e s s
than the surface visibility of four miles. Vis-
ibility could have been reduced in either a i r -
craft by windshield icing unless preventive
m e a s u r e s were used.
Since the DC-3 was equipped with s e v e r a l
transmitters and r e c e i v e r s i t i s considered
remote that total radio failure could have oc-
curred. As there were no radio contacts f r o m
the DC-3 i t i s unknown a t what altitudes the
flight was made. It would have been possible
for the pilot t o have conformed with VFR rules
between Battle Creek and Cincinnati by flying
through a r e a s of low ceiling and visibility at
l e s s than 700 feet altitude (below airways]
provided the a i r c r a f t was operated clear of
clouds and visibility was not l e s s than one
mile.
41
The elapsed time f r o m take-off of the
Martin 202-A, possible flight paths of both
a i r c r a f t and the techniques and flying habits of
both captains were thoroughly investigated.
TWA flight operations procedures specify
that a i r c r a f t a r e to climb straight ahead until
reaching an altitude of 500 feet. The flaps a r e
then retracted; power reduced to climb power,
and a climbing- t u r n to the desired heading i s
commenced.
Two t e s t flights were conducted to l e a r n
what the altitude and position of the a i r c r a f t a t
various stages would be i f standard company
procedures during instrument flight were fol-
lowed. The t e s t pilot had given the captain of
the Martin 202 his checks for the past 18 months
and i t was believed that this pilot could closely
duplicate the techniques which the captain proba-
bly used. The t e s t runs showed that the a i r c r a f t
would fly over the intermingled wreckage a t a n
altitude of 1 500 feet above the ground on a head-
ing of 340 to 345 degrees and in an elapsed time
of 2-1/2 minutes. Thus, a s the captain was a
. conscientious and conservative pilot who had
never been known to deviate f r o m company policy,
the collision probably occurred a t 1 500 feet.
An aeronautical engineer representing
Castleton, Inc. conducted a detailed study of the
wreckage and other evidence and submitted a
separate r e p o r t to the Board. He concluded
that the point of collision was very near the lo-
cation of the recovered DC-3 wing tip since this
unit fell straight downward after the collision.
His value of the closure angle between the two
a i r c r a f t a t the time of collision substantially
agreed with the Board's findings. P a r t of his
study was devoted to the calculated trajectory
of the DC-3 following collision. F r o m this ana-
lysis he concluded that the DC-3 struck the
ground 14 seconds after collision, and that i t
covered a distance of 3 000 feet over the ground
and rolled somewhat beyond the vertical i n this
interval. Based on conservative assumptions
he testified that the study further showed the
maximum collision altitude a s 1 000 feet, and
that if the elevator t r i m , the exact amount of
left wing lost, and elevator control displacement
(pilot's effort to r a i s e the nose of the aircraft),
were m o r e precisely known the collision altitude
might be a s loiw a s 500 feet. He further stated
that his study showed that the DC-3 heading was
170 :180 degrees and that of the Martin 202-A
was 315 - 330 degrees. The Martin heading a t
time of collision indicated that the TWA pilot
started his right turn a t the far end of Runway 22,
and that the collision occurred 50 seconds later.
42 ICAO Circular 50-AN/45
It i s reasonable to assume that the DC-3
was in level flight on a south heading. Whether
i t flew over Cincinnati or not could not be ab-
solutely verified. However, the DC-3 seen by
Witness No. 7 in West Cincinnati wae probably
the Castleton DC-3 a s no other DC-3's were
known to be in the area.
Since the DC-3 was not on an IFR flight
plan the pilot could be expected to have tried
to remain in visual contact with the ground.
Analysis of some witness testimony, however,
indicates that i t was being operated in the
clouds. The controller believed that he lost
sight of the TWA ~ i r c r a f due
t to its entry into
the overcast. Witness No. 1 states that an
appreciable period of time elapsed between
hearing the collision and the time an aircraft
came into view, apparently out of the ofer-
cast. Witness No, 5 stated that he saw an
explosion in the a i r which may indicate that
the collision occurred at the base of or in the
overcast.
During the several seconds i t took for the
eound of collision to reach the witnesses, the
ICAO Ref: A ~ / 3 7 5
inertia of the two aircraft would tend to make
them continue along the same general paths
they had immediately prior to the collieion.
As a result, the two aircraft may have changed
altitude very little during the interval dntil the
f i r s t witness saw the Martin.
The Martin 202-A i s capable of climbing
a t considerably higher rates than those indi-
cated by the test flight. Results of the test
flight indicated that collision occurred in the
clouds, several hundred feet above the base
of the overcast. However, the results of the
study by Castleton indicated that the accident
could have occurred between 500 add 1 000
feet. In considering the test flight results,
the engineering studies, and all other perti-
nent evidence, the Board concluded that the
accident occurred close to the base of, or in,
the overcast.
Probable Cause
The probable cause of this accident was
operation of the DC-3 in the control zone a s
unknown traffic, without clearance, very close
to the base of, or in, the overcast.
ICAO Circular 50-AN/* 43

CA8vLr+oiy INa 0O-m 1 N M . k

WLMI WLATLR C I W I W A T I AIRPORT
J*nuHT rz, torrs
44 ICAO Circular 5 0 - ~ N / 4 5
-
No. 6
Circumstances
At approximately 1150 hours the air-
craft, Oboe King, whilst taking off from
London Airport for Rome, Athens and Istanbul
crashed in conditions of bad visibility due to
fog, into a b a r r i e r in its path connected with
construction work which was thenand for some
time previously had been taking place in the
central a r e a of the airport. The captain and
f i r s t officer were both convinced before they
commenced their take-off that the aircraftwas
on Runway 6, also known as 15R, and they had
received radio-telephone clearance from the
airport control authorities to take off. In fact,
the aircraft was on a disused runway (here-
after called 'Ithe stript1), which had not been
used a s a runway since June 1949, when build-
ing operation6 in the central a r e a caused i t to
be closed. Although the ~ i r c r a f at t the time
of the crash was almost airborne and suffered
considerable damage, there were no casualties,
and only the captain and one passenger re-
ceived minor injuries.
Investigation and Evidence
The Airport is one of the largest and
busiest in the world and consequently there i s
perhaps both a greater likelihood of a pilot
losing his way at London than at most other
airports and also a consequentially greater
need for clear directions to enable him tofind
his way. Moreover, the size of the Airport
may make methods used at smaller airports
inapplicable. A further consideration i s that
London Airport has been ever since the war
in the course of development which i s not yet
completed. In consequence, there was onthe
day of the accident a lack of u n i f ~ r m i t yabout
marks and direction signs, etc. which was to
some extent inevitable in view of the rapid
development of the Airport.
It was not until the end of the war that
i t was decided to adapt the aerodrome for
use a s the main civil airport for London. At
the time when the Airport was taken over for
civil aviation there were three runways either
completed o r in the course of completion form-
ing a triangle with its base running in an east
and west direction parallel to and just south of
the Bath road (see Figure 5). It was decided
a) to superimpose upon the original trian-
gle of runways a second trianglewhich
would ensure there being two parallel
runways running in each of the three
directions of the original triangle and
b) to secure a greater length for the
runways.
The latter was done by an extension of
the runway forming the base of the original tri-
angle and one of the runways forming one of its
sides and by building for the third side a new
runway considerably further to the west running
from northwest to southeast and parallel to the
third runway constituting the original triangle.
Completion of this new runway and the prolonga-
tion of the two remaining runways constituting
the original triangle made it unnecessary any
longer to use the original northwest/southeast
runway. Moreover, development work upon the
central area of the Airport involved the obstruc-
tion and building upon part of the old runway.
Accordingly, it ceased to be used as a runway
on 28 June 1949. On the other hand, the build-
ing and development work only took place on the
centre portion of the old runway and those parts
of it to the northwest and southeast of such
work were of the same width and compositionas
runways in use at the Airport and also ran in
the same direction as the new runway construct-
ed further to the west.
The six runways in existence at the Air-
port at the time of the accident were known and
referred to in two different ways. One method
of distinction was to numb& the runways from
1 to 7 omitting number 3, which had been the
number of the strip a t the time when it was in
use as a runway. Another method, which is
more generally used and particularly for the
purpose of giving instructions to pilots either
landing or preparing to take off, i s designed to
 ICAO Circular 5 0 - ~ ~ / 4 5
distinguish the direction of the particular run-
way to which reference i s being made. Under
this nomenclature runways a r e numbered by a
two-figure number which represents the first
two figures of the magnetic compass heading of
the runway. Thus a runway which runs dueeast
and west magnetic, runs in a compass direction
of 270° o r 900 and such a runway under this
system would be called, if one were proceeding
from east to west, Runway 27 and, if proceed-
ing in the opposite direction, Runway 09. Since
at London Airport there a r e two runways in each
of the three directions, they haveto be distin-
guished from one another; this i s done by calling
them Right o r Left a s seen from an approaching
aircraft. The following table demonstrates the
two systems of numbering described above.
Numerical Compass bearing
Number Direction Number
Runway 1 East and West 28~/10~
Runway 2 North-east 05~/23~
South-west
Runway 4 North-west 3 3 ~ 1/ 5 ~
South-east
Runway 5 East and West 28~/10'R
Runway 6 North-west 33~/15~
South-east
Runway 7 North-east 05~/23~
South-we st
The length of the runways at London i s
approximately 7 000 ft. and thus affords ample
room for the take-off a+ landing of Viscount
aircraft. Each runway i s 300 ft. wide (save 2
which a r e 250 ft. ) and i s constructed of square
concrete slabs. The taxi-ways a r e similarly
constructed of concrete slabs but a r e only 125
ft. wide. So f a r a s dimensions and construc-
tion go "the strip" corresponded to the runways
and not to the taxi-ways.
Various methods a r e employed a t London
Airport for distinguishing the runways and
assisting pilots in finding their way about the
Airport. There a r e in addition certain objects
and signs at the Airport not intended for the
purpose of giving dGections but which never-
theless could in certain circumstances be used
to assist in identifying one's position.
Marks on the ground
There were at the time of 'the accident no
painted marks of any kind upon tither the strip
or any of the taxi-way s. On the other hand
there was a variety of marks painted upon some
of the runways as follows:-
45
a) Runway designation marks, also called
QDM marks. These marks, consisting
only of the compass heading designation
of the runway in large figures were
painted a t the beginning of Runways 10L
and 1 0 ~ / 2 8 L .
b) Runway threshold markings, also
known a s threshold strips. These
markings, consisting of a number of
parallel white lines 100 ft. long, were
only painted at the beginning o r thres-
holds of runways 10R and 2%.
c) Runway centre line markings. A bro-
ken centre line of white paint appeared
only on the two ~ a s t / ~ e runways
st
namely 28R/ 10L and 2 8 ~ / OR.
1
d) White crosses. At the time of the acci-
dent there were no white crosses painted
on the surface of any of the runways o r
taxi-ways o r upon the strip. A white
cross had been painted upon the strip
just south of its intersection with Run-
way 28R/ 1OL when the original runway
was closed but it had subsequently worn
out as a result of contractors' vehicles
using the strip and it had never been
repainted. The white cross had con-
sisted of a r m s not l e s s than 20 ft. long
and 3 ft. in width.
Notice boards and sign posts
a) Daylight route indicators. These con-
sisted of boards at the side of runways
or taxi-ways containing a r m s indicating
various directions open to a pilot pass-
ing the board, somewhat similar to the
boards which appear on fihe roads short-
ly before a junction a s an indication to
motorists. The appropriate a r m onthe
daylight indicator board i s intended to
be illuminated so a s to indicate to the
pilot the direction he i s to follow.
These daylight route indicator boards
a r e popular With pilots and eadily un-
7'
derstood by them, but at the, time of the
accident the completion bf tlie erection
of these boards and their eleictrical
equipment was far from complete and
none y a s available to show those in the
Viscount the right way to take on the
morning of the accident.
b) Position indicator o r block number
boards. The whole of the operational
part of London Airport including taxi-ways
46 ICAO Gircula
a s well a s runways has been divided up
into blocks each of which has been given
a number. Srnall boards at the side of
the runway and taxi-ways indicate the
boundary between one block and the
other by showing on their face the num-
b e r s of the two blocks in question. The
block number boards a r e relatively
small. The system of dividing the
operational part of the Airport into
numbered blocks and the use of block
number boards i s apparently peculiar
to London Airport and i s an extremely
useful way of readily identifying a par-
ticular portion of the surface of the
Airport.
c) QDM Boards. These a r e large boards
at the side of a runway indicating that
one i s shortly approaching another run-
way by showing in large figures the
compass heading number of the new run-
way. At the time of the accident these
existed in every case at the side of each
runway shortly before t&e intersection
or junction with another, except in the
case of the junction of Runway 28R and
15L.
d) Run-up boards. These a r e notice
boards at the side of runways shortly
before an intersection o r junction with
another runway indicating by words
such a s "Run-up for 15R" in large let-
t e r s and figures that the position has
been reached a t which aircraft about to
use the runway ahead should stop for
the purpose of running-up their engines.
At the time of the accident run-up
boards bearing clear and consistent
words and figures were in position in
all appropriate places at the Airport,
except at the junction of Runway 28R
with 15L where an old run-up board
bearing the phrase "Run-up 1" was in
existence. In some cases, however,
there were run-up boards on both sides
of the runway and in some cases only
on one side.
Lighting system
For the purposes of this report it i s only
necessary to deal with three different categories
of lighting.
a) Taxi-way lights. These a r e omnidirec-
tional lights let into the surface of the
concrete and were present both in the
runways and the strip. Their purpose
i s to guide aircraft to o r from a par-
ticular position on the Airport. The
lights a r e 80 ft, apart on straight
stretches and more closely together at
the curves. So far a s the qunways a r e
concerned these lights a r e not placed at
the centre of the runway but a r e closer
to that side which is nearer to the cen-
t r a l area. The lights a r e so placedthat
i f an aircraft straddles them it will be
able to proceed in safety.
b) Stop b a r lights. The division between
each of the blocks into which the opera-
tional part of the Airport i s divided i s
capable of being illuminated by red stop
bars, which a r e similarly let into the
surface of the concrete. In the case of
taxi-ways the red lighting proceeds in
an unbroken line from one side to the
other, but in the case of runways the
red lighting i s broken towards the centre
so a s not to interfere in any way with the
nose wheels of aircraft lanhing o r taking
off. At the time of the accident the taxi-
way lighting was fully installed and capa-
ble of being used as desired. It provided
a clear indication when switched on at
night and also in day time during a dark
fog. In the case of bright sunshine or fog
accompanied by bright light the green
taxi-way lighting was not obvious, though
it could be seen if specially looked for.
The installation of red stop bar lighting
had not been completed at the time of the
accident and it was only in use at night
time. The system i s designed so that
the green taxi-way lights and the redstop
b a r s can be used in conjunction, the for-
m e r indicating to a pilot the way he has
to go and the latter both protecting his
route from others and also serving the
secondary purpose of keeping him onthe
way indicated by the green taxi lights.
c) Runway lights. These a r e a double row
of lights let into the concrete of the run-
ways and shining up and down the runway
only. Their use was and i s for the as-
sistance of pilots taking off and landing
in darkness or in conditions of poor vis- I
ibility. At the time of the accident all
except Runway ~sLR~R.
runways were equip ed with these lights
such lights on the strip.
There wereno
At the beginning of the runways at London
Airport and some 70 yards to one side of their
edge i s a hard standing place for what is called
the Runway Controller's caravan. This caravan
 ICAO Circular 50-~N/45
moved from the beginning of one runway to
w t h e r in accordance with the decision of the
Airport authorities from time to time a s to
which runway i s to be used.
In addition to the above, information re-
garding the various runways and taxi-ways a t
London Airport is published from time to time
for the use of aircraft operators and their pi-
lots. The captain and the f i r s t officer had avail-
able to them in their aircraft a publication is-
rued by International Aeradio Limited (known a s
Itthe Aerad"), which on one plan, called the
Landing Chart, indicated the direction and com-
pass heading numbers of the runways at London
Airport a s well as showing the strip and the
taxi-ways, and on another plan, called the Traf-
f i c Blocks Plan, showed the system of block
@umbering.
Ground Control System
No aircraft at London Airport i s allowed
to move along the taxi-ways o r runways unless
prior approval has been obtained from the ap-
propriate controller. A short description fol-
lows of the control exercised on aircraft oh the
ground by two controllers called the Ground
Movement Controller and the Aerodrome Control
Officer (Air). They a r e assisted by information
obtained by them from the Runway Controllers
at the runways in use at the particular time.
The Ground Movement Controller and the Aero-
drome Cont. 31 Officer (Air) at the time in ques-
tion worked side by side in the old control tower
to the north of Runway 1 and just south of the
Bath road; they now work in similar proximity
in the new control tower. The Ground Movement
Controller (subsequently called the "Ground Con-
trollerwt)i s responsible for the control of taxyiag
aircraft and also that of directing aircraft and
all vehicles on the movement area. His col-
league, who i s generally known for short.as the
"Air Controllertq, has the duty of controlling the
take-off and landing of aircraft. When conditions
are good he has also more extensive duties in
relation to landing aircraft, but on 16 January at
the time in question all landings were instrument
landings and the Air Controller was in conse-
quence only concerned with approaching aircraft
When they had become the next to land.
Each of these two controllers i s in radio-
telephonic communication with aircraft. Each
uses a different radio frequency and i s not able
to listen in to the frequency of his colleague. In
the case of aircraft proceeding to a take-off posi-
tion it is, in the case of piston-engined aircraft,
the duty of the Ground Controller to direct the
aircraft and control it during its passage from
47
the parking area to the run-up point for the run-
way in question. If the approach of the aircraft
to the run-up point necessitates the crossing of
a runway in use, the Ground Controller will not
allow the aircraft to cross such runway until he
has received permission frotn the Air Controller.
In the case of piston-engined aircraft, the
Ground Controller will normally hand over the
aircraft to the Air Controller once i t has reached
the run-up point. It then becomes the duty of the
Air Controller to take the aircraft to the take-off
point and in due course give it clearance for take-
off.
A difference of practice, of some impor-
tance in this Inquiry, obtains in the case of
turbine-engined aircraft since these require a
much shorter period for running up their engines
before taking-off than do piston-engined aircraft
and lengthy running of turbine engines on the
ground is to be avoided because of the unecommic
consumption of fuel thereby entailed. Accord-
ingly, in the case of turbine-engined aircraft it
hae been the practice for the Ground Controller
to hand such aircraft over to the Air Controller
whilst the aircraft in question i s approaching
what for a piston-engined aircraft would be the
run-up position. The object of this difference in
practice i s to avoid unnecessary delay to turbine-
engined aircraft, which will, if at all possible,
in consequence not pause a t the run-up position,
but proceed straight to the take-off point and
there do any necessary running up of their
engines ,
In the case of i t s being necessary for a
taxying aircraft to cross a runway in use, not
only is permission sought by the Ground Control-
ler from the Air Controller before crossing i s
permitted, but once such permission has been
given the Air Controller places a strip marked
IwRunwayObstructedwtacross the plan of the run-
way on the board in front of him so as to ensure
that he should not by any oversight give clear-
ance to an aircraft to take-off or land before the
taxying aircraft has completed the crossing.
Assistance to the Ground and Air Con-
trollers in the control tower was and i s provided
in certain circumstances by the Runway Con-
troller in his caravan at the beginning of each
of the runways in use at any particular time.
The Runway Controller's caravan i s connected
by three radio-telephone loud-speakers to the
circuits of the Ground Controller, the Air Con-
troller and the Ground Controlled Approach.
He is also connected by telephone to the control
tower and to the switchboard of the Airport.
His duties a r e to log the time of aircraft taking-
off and landing, to see that runways in use a r e
48 ICAO Circuilar 5 0 - ~ ~ / 4 5
kept clear and that there i s nothing amrss with
aircraft passing him to take off o r about to
land. When visibility i s bad the duties of the
Runway Controller a r e increased and also
become of much greater importance since, in
addition to his duties in clear weather which
remain, he has the additional task of calculating
the runway visual range by reference either to
the marks situated a t the sides of the runway or
to lights and flares situated at certain fixed dis-
tances along the side of the runway in question.
The duty of calculating the runway visual range
falls upon the Runway Controller whenever vis-
ibility falls below 1 200 yards and he has to
report any change in runway visual range by
telephone to the Control Tower. It is worthy of
note that the practice of using Runway Control-
l e r s a s described above, which is often of value
a s an additional safeguard, is, it i s understood,
only followed at United Kingdom airports.
The Accident
Visibility was too bad for Oboe King to
attempt to take-off at the scheduled time and it
was not until about 1120 hours that there was
sufficient visibility on the runways for the cap-
tain to consider moving Oboe King from the
parking place, which was in block 18 a t the ex-
treme east end of Runway No. 1 o r 28R. The
captain being in radio-telephonic communication
with the Ground Controller, heard the periodical
statements issued by him of the runway visual
range at each of the two runways in use that
morning, namely Runway No. 6, or 15R, and
Runway No. 5, or 10R. The minimum runway
visual range laid down by British European Air-
ways as required for a Viscount to take-off at
London Airport was 150 yards, this being con-
sidered the minimum necessary to enable a pi-
lot to keep his aircraft on a straight course
when moving along a runway to take-off. At
1123 the captain informed the Ground Controller
he would like to start if the then runway visual
range of 150 yards was maintained and at 1133
the aircraft was given permission to and did
start its engines.
Shortly after this the captain informed the
Ground Controller that he wished to use Runway
15R and this was approved. He had only once
previously taken-off on that runway, but chose
it on this occasion since he was late and it was
the nearer of the two runways in use. There
was also some indication that it had the better
visibility. He then received his airways clear-
ance, or initial routing instructions, for Rome
and at 1138 hours received permission to taxi
west along Runway 28R to the holding position
for Runway 15R. The Ground Controller at the
/
same time asked the captain to let the Control-
l e r know a s a check when Oboe King passed the !
Control Tower and when it was clear of Runway 5
23R. The Control Tower would have to be
passed to starboard at a distance of some 300
yards, whilst Runway 23R would have to be
passed to port some 500 yards beyond the Con-
trol Tower.
The captain and the f i r s t officer, whohad
never previously taken off from Runway 15R,
consulted the Aerad they had on board in order
to ascertain their route to 15R before moving
off from their parking place. They observed
that they simply had to proceed straight for the
full length of 28R in order to arrive at 15R.
The pages which they consulted showed the var-
ious turnings off 28R in the course of its length,
including Runway 23R and the strip. There was
no clear indication on the plan that the strip was
not in use and none that it was obstructed a t any
point in its length. The Aerad was kept open
between the captain and the f i r s t officer in the
cockpit whilst the aircraft taxied to its assumed
take-off position, but i t was never again con-
sulted by either of them. Neither pilot attempt-
ed to count from the Aerad the turnings that
would have to be passed before the end of Run-
way 28R was reached so as to be able to check
the number as the aircraft passed them.
The first officer at the controls concen-
trated on keeping the aircraft on the centre line
of the runway. The captain also had a close
regard to this, but also noticed green taxi
lights cross his path from starboard to port and
lead off down Runway 23R. He saw no other
green taxi-way lights and the f i r s t officer no-
ticed none at all. The Board i s satisfied that
the green taxi-way lights leading to the end of
the runway were switched on at the time and
could have been seen after the junction with
23R had the captain or first officer been con-
cerned to pick them up. The captain was able
to see the Control Tower as he passed it and
reported this as requested. He next reported
passing Runway 23R as he had also been re-
quested.
The distance from the edge of the con-
crete at the entrance to 23R to the nearest
edge of the concrete at the entrance to the
strip i s only some 150 yards, whereas the
distance from the same edg&of 23R to the end
of Runway 28R i s about 1 100 yards. Notwith-
standing this both the captain and the f i r s t of-
ficer when they came to the junction between
the strip and Runway 28R thought they had come
to the end of the latter. They both thought they
saw ahead of them the end of the concrete, they
 ICAO Circular 5 0 - ~ ~ / 4 5
saw something which so far a s width and sur-
face were concerned appeared to be a runway
on their port side, and they observed that its
magnetic heading was 1500. They both accord-
ingly felt quite sure they had reached 15R and
Oboe King was swung round to port so as to be
ready to take-off. No steps were taken by ei-
ther pilot to'check their position although they
did observe a block number board on their port
side, the number on which they could not read
as it was edgeways on to them. At the time in
question the fog was extremely dark and the
conditions were such a s the captain had never
before experienced. Apart from a military
transport operation in wartime the f i r s t officer
had never taken-off in similar conditions with-
out the aid of lights. There wereno lights,
whether taxi-way o r runway, showing on the
strip at the time.
Shortly before reaching its position on
the strip Oboe King, pursuant to the practice
with turbine-engined aircraft already mentioned,
was passed over from the Ground to the Air Con-
troller. At 1143 the pilot reported to the latter
as being in the holding position on Runway 15R
whereas in ta'uth the aircraft was on the strip.
Runway visual range had then deteriorated to
100 yards on 15R so Oboe King had to await an
improvement. Whilst taxying to this position
the captain had heard conversations between
Ground Control and a Trans Canada Constella-
tion which, owing to bad visibility, was return-
ing from Runway 10R to the parking place via
Runway O~A.,, which in the reverse direction i s
23R and crosses the strip towards its north-
eastern end. At 1145, whilst waiting in position
at the strip, the captain thought he saw the Con-
stellation and reported to the Air Controller
that he saw it cross the take-off end of 15R and
enter 10L, i. e. cross in front of Oboe King and
turn to the right in the direction of the parking
place from which Oboe King had come. Q-I fact
the captain did see the Constellation, but he saw
it a t the intersection of Runway 23R and the
strip and not a t the intersection of Runway 23R
with Runway 15R at the beginning of which the
captain thought he was.
At 1148 runway visual range on 15R was
reported a s 200 yards and the captain requested
clearance to take off which he was given. He
was told the runway was clear and that there
were no other taxying aircraft. He then com-
menced his take-off along the strip and when
about to become airborne crashed into the bar-
rier. Between starting to move down the strip
and the moment of the crash the Air Controller
asked him whether he was some distance down
15R and was told that he was llrollingHabout
49
200 yards down 15R. This request by the Air
Controller had been prompted by a telephone
call to him from the Runway Controller at the
beginning of 15R, who could not see Oboe King,
but who from the sound of its engines had
thought it was some way down Runway 15R,
possibly at the intersection with Runway 23R.
The Runway Controller heard the sound
of the crash and reported this to the Air Con-
troller a t once. The alarm was immediately
given, but since no one at the time knew the air-
craft had taken off on the strip and vision was
obscured by the fog, the rescue teams were
originally given inaccurate directions. In con-
sequence they did not reach the scene of the
accident until some ten minutes later.
The captain was in command of the air-
craft at the time and was, in accordance with
the Operations Manual of British European
Airways, responsible for exercising opera-
tional control of his aircraft. He frankly rec-
ognized at the Inquiry that in taking off on the
strip he had made a mistake.
No accident would have happened but for
the fog. Both the captain and the first officer
had no doubt whatever of their position; had
they been in doubt there were various methods
available to them of checking where they were
which they would no doubt have used. The
question, however, i s whether in the circum-
stances then prevailing they should have al-
lowed themselves to be so confident of their
position that they did not seek any check to
make certain that their confidence was well
founded.
It can be said that there was no positive
mark or sign visible to the pilots to indicate
that they were not in the correct position to
take-off, that the strip was, so far as width
and surface material were concerned, indis-
tinguishable from a runway, that its magnetic
heading was correct and that before taking off
Oboe King had been specifically informed in
answer to an enquiry that the runway was clear.
As against these considerations, however,
both pilots appreciated that in proceeding from
their parking place along Runway 28R to their
assumed take-off position they had been moving
in condition$ of very poor visibility resulting
from a dark fog. In foggy conditions it i s dif-
ficult to judge distances and easy to imagine
things at o r near the extreme range of vision
which a r e not in fact what they appear to be.
The captain should not have relied, as he did,
without any other check upon what he thought
50 ICAO Circular
he saw in the dark fog to be the end of the con-
crete of Runway 28R, even though this was cou-
pled with the existence on the right compass
heading of the concrete surface of the strip.
The conditions for take-off which confronted
him when he turned into the s t r i p were such a s
he had never previously experienced at London
Airport in that there was a dark fog and there
were no runway lights to assist the take-off.
Had he not been over-confident the Commis-
sioner finds i t difficult to believe that he could
have mistaken the 150 yards distance from the
entrance of Runway 23R, which he correctly
identified and reported to the Control Tower,
with the distance of about 850 yards which he
should have traversed after leaving the junction
with 23R before reaching his correct position
at the beginning of Runway 15R. He did not
make a full use of the Aerad Landing Chart. He
could, had he been concerned to verify his posi-
tion, have picked up the green taxi-way lights,
at intervals of 80 yards, leading on from the
junction with Runway 23R to the correct position
for take-off. He could, when he saw no taxi-
way lights ahead and no runway lights on the
strip, have communicated with the Air Control-
l e r and asked for these to be switched on. It i s
also true that he could, had he been in any doubt,
have checked his position accurately by approach-
ing nearer to the side of the strip so a s to have
been able to read the numbers upon the block
number board which he did notice edgeways on
a t the side of the strip. The Commissioner
does not feel, however, that in this respect
alone the captain could be criticised if he had
in any other way verified his position, These
block number boards a r e small, peculiar to
London Airport, and their use does not readily
appeal to pilots, who cannot be expected to re-
member the numbers if read and must check
them by reference either to the Control Tower
o r a detailed plan in their Aerad.
The Commissioner concluded, therefore,
that so f a r a8 the captain is concerned he made
a mistake due to over-confidence. He should
have checked his position, and his omission to
do so was a cause of the accident.
The first officer was not, of course, in
command of Oboe King. He was, however,
controlling the aircraft and had the same op-
portunity for observation a s had his captain.
The Commissioner considered whether the
presence of the captain in command of the air-
craft can completely exonerate the f i r s t officer,
but does not think that such a conclusion would
be right. If the argument were accepted that
in circumstances similar to this case the first
officer could rely exclusively upon his captain
taking full responsibility there might be a seri-
ous risk of a reduction in the high standard of
care at present exercised by, and indeed ex-
pected of, f i r s t officers. Since the f i r s t officer
was in physical control of the airc1;aft he should
have satisfied himself that he was in the right
position before he took off; the position might
be different had he expressed doubts a s to his
position to his captain and been over-ruled by
him. The f i r s t officer was a s equally over-
confident a s the captain and like him should
have checked his position before taking off.
His over-confidence was also a cause of the
accident, though his responsibility was less
than that of the captain.
In dealing with the above matters the
Commissioner did not rely upon o r mention the
lack, on or near to the entrance to the strip,
of any of the various marks on the ground o r of
the notice boards and sign posts, other thanthe
block number board. He excluded the lack of
these various indications, which might have
caused doubt to those in the aircraft of their
position, because of the lack of uniformity at
London Airport at the time of the accident. It
was difficult enough when members of the Air-
port staff were giving evidence for them to re-
member what particular notice boards o r
marks were to be found at or about the entrance
to any particular runway and no pilot, using
London Airport amongst many others, could
hope to memorize the various differences.
Moreover the lack of uniformity, to which pi-
lots using London Airport have become accus-
tomed during the many changes consequent
upon its rapid development, has not unnaturally
led them not to place too much reliance upon
the absence o r presence of any particular marks
or notice boards. Nor can those in the aircraft
be blamed for not having noticed the absence of
the Runway Controller's caravan. In any case
this would have been some 70 yards from the
side of the runway and, in the conditions of fog
prevailing, might not have been visible. More-
over the exact position of the caravan a t the
beginning of particular runways is subject to
some variation.
So far a s the action of the Ground and
Air Controllers was concerned, they had
available between them information which, if
present to one mind, might well have led to
action preventing the acci'dent. Thus the
Ground Controller, having passed over Oboe
King to the Air Controller at about 1142, did
not hear the subsequent conversation between
the Air Controller and Oboe King regarding
the Trans Canada Constellation. On the other
hand, the Ground Controller knew, at about
 ICAO Circu l a r 5 0 - ~ ~ / 4 5
the time of such conversations with the Air Con-
troller, of the exact position of the Constella-
tion, which had been verified by a conversation
between the Constellation and the Ground Con-
troller himself by reference to a block number
board. If the Ground Controller had known
that Oboe King, from what was assumed to have
been the holdihg position at the beginning of
Runway 15R, had seen the Constellation c r o s s
the take-off end of that runway and enter Run-
way 10L, he would probably have realized that
something was wrong. However, the separate
knowledge, which each of the two Controllers
had, was not by itself sufficient to indicate to
either that Oboe King was out of position. The
work to be carried out in the Control Tower
necessitates a division between the Ground and
Air Controllers and i t would be impossible to
combine their duties. O n the other hand, some
alteration may well be desirable, in conditions
of bad visibility, in the practice mentioned
above of the Ground Controller handing over to
the Air Controller turbine-engined aircraft a t
an e a r l i e r time than piston-engined a i r c r a f t a r e
handed over. Thie point i s dealt with in the
recommendations later in this Report. It should
be added that the Ministry of Transport and
Civil Aviation a r e in the course of installing a t
London Airport a radar device, called ASMI,
which when in working order will allow the Con-
trollers in the Tower to s e e on the radar screen
any aircraft o r vehicle moving upon any of the
runways even in conditions of dense fog.
The d~tciesof the Runway Controller have
been s e t out above and i t has been pointed out
that in conditions of bad visibility these duties
a r e both increased and become of much greater
importance. At the time of the accident there
was a Runway Controller in his caravan some
70 yards to the east of the edge of Runway 15R
and v e r y near its beginning. The Controller in
question had three radio-telephonic loud speak-
e r s operating at the same time in his caravan,
though one of these was toned down, and also
had to be constantly estimating the runway vis-
ual range and reporting this by telephone to the
Control Tower. Had the Controller been able
to give unfettered attention to what was being
said on the two loud speakers connected to the
Ground Controller and the Air Controller, he
might have realized that whereas Oboe King had
reported that i t was at the holding position on
Runway 15R, the aircraft was not visible f r o m
his caravan nor could i t s engines be heard.
The Controller in question frankly admitted that
had he heard Oboe King's report of i t s position
he would immediately have informed the Tower
that the aircraft was not where i t had reported
itself to be and the accident would have been
51
prevented. It is noteworthy that once Oboe
King had started i t s take-off the Controller was
the f i r s t person to realize that something was
amiss. He heard Oboe King receive clearance
to take off and expected to see the a i r c r a f t turn
on to Runway 15R. In fact he did not see the
aircraft and heard what sounded like a Vis-
count's engines coming f r o m a southeasterly
direction. He immediately telephoned to the
Control Tower a s a result of which the Air Con-
troller spoke to Oboe King while it was actually
running down the s t r i p , a matter of seconds
before the c r a s h but this intervention was then
too late.
At the hearing it was argued that in more
than one respect the action o r inaction of the
Ministry of Transport and Civil Aviation, the
owners of London Airport, was responsible f o r
and a cause of the accident. In the f i r s t place
i t was suggested that the entrance to the s t r i p
should have borne a white painted c r o s s upon
the concrete in accordance with Paragraph 51
of the "Rules of the Air and Air Traffic ControlI1
in Schedule I1 to the Air Navigation Order, 1954.
The relevant part of this rule provides that 'kt a n
aerodrome which has one o r more runways
clearly visible white crossee shall be displayed
at each extremity of a runway which becomes
unfit for use. l1 It wae argued that the s t r i p was
a runway which had become unfit for use and
that accordingly white c r o s s e s should have been
used a t its extremities. It was further pointed
out that when the runway was originally closed
a white c r o s s had been painted on the concrete a t
more o r l e s s the position occupied by Oboe King
when waiting for take-off clearance. The Com-
missioner does not consider this argument
sound since the strip, although it had once been
a runway, was not in fact a t the material time
a "runwaytt within the meaning of the rule. The
word "runway" must, on i t s true construction,
mean something which i s normally used f o r the
take-off and landing of a i r c r a f t and this was in
no sense the use made of the s t r i p a t the rnate-
r i a l time. There is a somewhat similar provi-
sion in Annex 14 to the Convention on Internation-
al Civil Aviation, which, in P a r t V, Chapter 3 a t
Paragraphs 3.4.1 and 3.4.4, provides for the
use of a white c r o s s to indicate that any part of
the movement a r e a of an aerodrome i s unfit f o r
the movement of aircraft, The s t r i p was, how-
ever, not unfit for the movement of a i r c r a f t f o r
the purpose of taxying and was i n fact considera-
bly used in this way. It cannot therefore be said
that there was any departure f r o m this Standard.
A more serious charge against the Minis-
t r y was that there should have been QDM marks,
o r runway designation markings on each runway
 52 ICAO Circula
at the airport, This is provided for i n P a r t VI,
Chapter 2, Paragraph 2.2.2 of the same Annex
14, and i s also a Standard. A Standard i s a
practice which by definition "is recognized a s
necessary for the safety o r regularity of interna-
tional a i r navigation and to which the Contract-
ing States will conform in accordance with the
Convention; in the event of impossibility of com-
pliance notification to the Council is compulsory
under Article 38 of the Conventionu. The United
1 Kingdom i s one of the Contracting States and the
Ministry should accordingly have complied with
this particular Standard. No notification of the
impossibility of compliance had been given, nor
was it argued that compliance was in fact im-
possible. It was admitted before the Commis-
sioner on behalf of the Ministry that there had
in fact been a failure to comply with this par-
ticular Standard and it was argued on behalf of
the captain and the f i r s t officer that, had the
Standard been complied with, the absence of
QDM marks on the strip would have indicated to
them that they were not on a runway. QDM
marks a r e intended to assist the pilot in an air-
craft about to land and a r e not used for the pur-
poses of take-off. Whilst it is just possible that,
had QDM marks been in position on all the run-
ways in use at London Airport, the absence of
such marks on the s t r i p might have caused the
captain and the f i r s t officer to have had some
doubt a s to their position, the Commissioner
finds it impossible to satisfy himself that such
a result would have been probable. Accordingly,
he cannot find that the absence of QDM marks
was a cause of the accident.
There i s a further Recommendation in
Amex 14 to the Convention on International Civil
Aviation contained in P a r t VI, Chapter 2, Para-
graph 2.6.1 which recommends that a longitudi-
nal marking consisting of a continuous white
line six inches wide should be painted along the
centre line of all paved taxi-ways, It is sug-
gested that, if this Recommendation had been
carried out, such a white line down the centre
of the strip would have been a clear indication
to those in Oboe King that it was not on a run-
way and the accident would have been prevented.
It i s possible that the existence of such a white
line would have prevented the accident. The
Ministry had given considerable thought to
whether or not this Recommendation should be
adopted both a t London Airport and elsewhere
in the United Kingdom and had decided against
it for reasons which a r e discussed later in the
section of this report dealing with recommenda-
tions. Whatever may be the right conclusion
whether or not this Recommendation should on
general grounds have been complied with the
Commissioner does not think it possible to find
that the Ministry and those who a r e responsible
for London Airport can in any way be said to
have been lacking in care o r foresight in not
anticipating that, in the absence of such a con-
tinuous white line, an aircraft would, in condi-
tions of bad visibility, have attempted to take
off f r o m the s t r i p in mistake for a runway.
Some evidence was given at the lnquiry
that on three separate occasions in bad visibil-
ity the pilots of aircraft taxying either along
Runway 28R or Runway 23R had, on coming to
the junction with the strip, momentarily doubted
their position and thought that the strip might in
fact be a runway. ~ o t h i n happened
~ in anyof
these three cases since the pilot in question was
able to make sure of his position, almost a s
soon a s the doubt occurred to him, in one way
o r another. None of these three incidents, if
incidents they can be called, was ever reported
to the authorities responsible for the Airport.
The Ministry and Airport authorities a r e
fully conscious of the undesirability of a lack
of uniformity in the markings and sign posts
and other indications of position in use at the
Airport. Some of the lack of uniformity has
been due to the development of the Airport
since the war which i s still not yet completed.
But notwithstanding the undesirability of lack
of uniformity the Commissioner cannot find
that either the Ministry or the authorities at
the Airport through what they did o r omitted to
do as regards the marking o r sign posting of
runways, taxi-ways and the s t r i p can be held
responsible for the most unusual combination
of circumstances which led to the present acci-
dent, or can be said to have caused such acci-
dent within the meaning of the word tlcauselfin
Paragraph 9(17) of the Civil Aviation (Investiga-
tion of Accidents) Regulations, 1951,.
Probable Cause
The captain and f i r s t officer did not check
in the conditions of bad visibility obtaining to
see that they were in fact lined up on Runway
15R for which they had been cleared for take-
off. As a result the aircraft collided with the
b a r r i e r and other obstacles on the s t r i p conse-
quent upon the aircraft commencing to take off
on the s t r i p instead of Runway 15R.
Re commendations
I
It seems highly improbable that an acci-
dent of this type will ever occur again upon the
strip since a most unusual set of circumstances
is necessary before i t can occur. Further, the
introduction in due course of ASMI should as
long a s that apparatus is in working order and
properly used render such an accident impossible
 ICAO Circular 5 0 - ~ N / 4 5
All reasonable s t e p s must be taken to prevent
any possibility of such an accident recurring and
it will not be satisfactory to rely exclusively on
ASMI which may well, even after i t s introduc-
tion in full working order, f r o m time to time
become unserviceable.
It i s clearly desirable, a s was indeed rec-
ognized by the Ministry, that appropriate notice
boards should be erected a t either end of the
s t r i p s o a s to give warning in conditions of bad
visibility that the s t r i p i s not to be used a s a
runway. The Commissioner recommends that
at the entrance to the s t r i p in blocks 2, 11, 21
and 85 notice boards on each side of the s t r i p at
least a s large a s those used for run-up boards
should be s e t up bearing the words "Taxi-way
onlytt. Also that a t the entrance to the s t r i p in
blocks 2, 11, 21 and 85 the words "Taxi-way
onlytt should be painted in large white l e t t e r s
a c r o s s the concrete of the s t r i p .
L€ the information possessed by each of the
Controllers in the Conttol Tower had been avail-
able to only one of them, it i s possible o r even
probable that the accident would have been avoid-
ed. Such information would have been available
to the Ground Controller had he not handed over
Oboe King to the Air Controller before i t reached
the run-up position for Runway 15R in accordance
with the practice followed in the case of turbine-
engined aircraft. In conditions of bad visibility
i t s e e m s unwise that the Ground Controller
should relinqnish control of any a i r c r a f t until i t
is reported a s having reached either the run-up
o r take-off positions. Accordingly, i t is recom-
mended that in conditions of bad visibility, by
which i s meant conditions in which runway vis-
ual range i s being ascertained and reported, the
Ground Controller should not hand over control
of turbine-engined a i r c r a f t until they have reach-
ed either the run-up position o r the take-off po-
sition for the particular runway to be used.
The Runway Controllers a t London Airport
clearly have a v e r y useful function t o perform
in conditions of bad visibility. In such circum-
stances, however, they have more to do than
they can hope always to c a r r y out to their com-
plete satisfaction and in consequence their value
i s thereby s o much reduced. 1t would be a wise
precaution if clearance f o r take-off was never
given in conditions of bad visibility by the Con-
t r o l Tower to any a i r c r a f t until the Control
Tower had received f r o m the appropriate Runway
Controller a telephonic report that the a i r c r a f t
was in the proper take-off position f o r the run-
way in question. It is, accordingly, recommend-
ed that this practice be adopted for the future in
conditions of bad visibility.
53
The recommendations in the two fore-
going paragraphs a r e of general application and
a r e not limited to conditions a t London Airport.
During the evidence of the captain he was
asked whether he was satisfied with the mini-
mum visibility for take-off of 150 yards laid
down by British European Airways f o r London
Airport. His answer was that he thought it
r a t h e r low and that he would prefer the figure
of 600 yards, which i s the minimum visibility
for landing, since 150 yards would in the major-
ity of c a s e s be quite inadequate for a pilot to
take avoiding action should there be any obstruc-
tion on the runway. He made i t c l e a r , however,
that he had no fault to find with the minimum of
150 yards, provided that it was possible to be
absolutely s u r e that t h e r e was no obstruction in
the way, a s would be the case for example when
ASMI o r some s i m i l a r r a d a r device was in oper-
ation.
The minimum visibility for take-off at
London Airport laid down by British European
Airways for Viscount Aircraft is:-
a) based on the assumption that the runway
i s f r e e f r o m obstruction;
b) designed to ensure that the pilot can
keep his a i r c r a f t on a straight course;
and
c ) always subject to the decision of the
captain of the a i r c r a f t himself.
In other words, notwithstanding the existence of
the minimum visibility, the captain is f r e e to de-
cide whether in a l l the circumstances he should
o r should not take off. The course of Oboe King
along the s t r i p up to the moment of impact was
perfectly straight, a s was demonstrated by the
wheel marks on the concrete, and accordingly
confirmed the suitability of the minimum s o f a r
a s keeping a straight course is concerned. The
Commissioner does not consider that the most
unusual f a c t s of this accident a r e sufficient to
justify a recommendation that the minimum
should be increased. The concurring f a c t o r s
leading to this accident a r e most unlikely to be
repeated and should be rendered well nigh im-
possible if the above recommendations a r e put
into effect.
The final question i s whether i t should be
recommended that the Ministry of Transport
and Civil Aviation take s t e p s both at London Air-
port and elsewhere, but particularly a t London
Airport, to c a r r y into effect the Recommendation
a s to a continuous thin white line down the c e n t r e
 54 ICAO Circula
of taxi-ways contained in Annex 14 to the Con-
vention on International Civil Aviation, P a r t VI,
Chapter 2, Paragraph 2.6.1. One of the prob-
lems that has exercised the authorities respon-
sible f o r London Airport in connection with the
s t r i p i s to find some mark o r indication which
would, whilst indicating that the s t r i p was not a
runway, also indicate that i t was appropriate for
use a s a taxi-way. The continuous white line
device would seem at f i r s t glance to satisfy the
necessary requirements and has the additional
use, which is-its main purpose, of assisting
taxying aircraft to keep to the centre of the taxi-
way in low visibility.
Apart from the weight naturally to be given
to a Recommendation of the International Civil
Aviation Organization, evidence was given that
the continuous white line device was in use at
various Continental and Irish airports. It has,
however, not been adopted at any United Kingdom
airport under the control of the Ministry. The
chief witness called on behalf of the Ministry did
not consider that a s a matter of general applica-
tion this Recommendation was a useful one, since
he thought that taxi-way lights and daylight route
indicators were a more valuable indication a s to
the use of taxi-ways. Furthermore, a continu-
ous white line would involve considerable ex-
pense both in its installation and maintenance.
In regard to London Airport, in addition to the
above disadvantages, the continuous white line
would, he thought, give r i s e to confusion at
inter sections rather than facilitate the task of
pilots finding their way about. Further, he
pointed out that a t London Airport it i s often
necessary to use one o r more runways a s a taxi-
I way, but it would be clearly impossible to paint
the continuous white line down runways. This
would a t once result in a lack of uniformity in
the meaning of a continuous white line down the
centre of a concrete paved way.
The Ministry favoured the extensive use
of taxi-way lights, stop b a r s showing red lights
and daylight route indicators a s the best solu-
tion of the problem and there i s no doubt that
the system of lighting a t London Airport, which
works in conjunction with the block number sys-
tem, i s one of much ingenuity and has been
designed and installed with great c a r e and no
inconsiderable expense. The system has the
whole-hearted support of the experienced pilots
using London Airport who were called to give
evidence but they all stressed that it was essen-
tial that an intelligent use should be made of the
lighting system by those in control. They urged
that an aircraft should not be expected, for ex-
ample, to have to c r o s s any line of green taxi-
way lights a s was Oboe King on the day of the
accident in relation to the lights leading from
the direction of the old Control Tower across
its path on Runway 28R and down Runway 23R.
There i s little doubt that, when the completion
of the installation of the daylight route indica-
tors and all the taxi-way lights and stop bars
has taken place, the control staff df London
Airport will make the fullest and most intelli-
gent use of this elaborate and expensive direc-
tional apparatus which will be at their disposal.
Moreover, experience will, no doubt, indicate
its best use. So f a r as i s known, London Air-
port i s the only airport at present installing the
ASMI radar apparatus. This fact indicates both
the care for the safety of those using London
Airport exercised by the responsible authorities
and the likely reduction to the barest minimum
in the future of any serious consequences of the
pilot losing his way should this by some mis-
chance prove possible.
If all runways at London Airport were
provided with runway centre line markings of th
6roken line type, as-recommended and describe
in Annex 14 to the Convention on International
Civil Aviation, P a r t VI, Chapter 2, Paragraphs
2.2.7 and 2.2.8, then the absence of any longitu
dinal markings on the taxi-ways would provide a
definite indication to a pilot that, when he was
on a concrete s t r i p devoid of longitudinal rnakk-
ings, he was not on a runway.
1
The Commissioner does not feel able on
the basis of the limited evidence available to
him of the use of taxi-ways and runways at I
London Airport, to make a general recommen-
dation that the Ministry should forthwith insti-
tute the continuous white line on taxi-ways at
all airports under their control in the United ,
Kingdom. There appears to be weight in some
of the objections of the MiniBtry, which the
Commissioner has surnrnarized, to such a
recommendation. Nor was it at present fa- I
voured by British European Airways.
The Commissioner recommends that the
Ministry give further study to this problem
with a view to choosing a system of marking
which will provide a continuous indication to
aircraft on-the ground whether they a r e on a
taxi-way o r on a runway. Among systems at
present approved internationally the choice
seems to lie between painting longitudinal cen-
t r e line markings along all taxi-ways in accord-
ance with the Recommendatibn in Annex 14 to
the above Convention, Part VI, Chapter 2, Para-
graph 2.6.1, o r painting centre line markings
of the broken line type described in Paragraph
2.2.8 in accordance with the Recommendation
in Paragraph 2.2.7 on all runways, leaving all
taxi-ways unmarked by any longitudinal paint
markings. In the course of their further study
 ICAO Circular 50-AN/& 55

no doubt the Ministry will in particular collect
evidence a s to the success o r otherwise of the
use of the longitudinal white line on taxi-ways
at large and busy airports in other countries.
Such experience will probably in time resolve in
one way o r another the doubts expressed a s to
the desirability of adopting the longitudinal white
line on taxi-ways in this country in general and
at London Airport in particular .

ICAO Ref: A R / ~ O ~
I

MAINTENANCE AREA

LONDON AIRPORT
LOCATION OF TRAFFIC BLOCKS
- - --------
-- - -- -- !
l n M S SHOWN THUS NOT VET COMPLETE I
1I

i
i 0 &
SCALE* MILES
4 M
I
I
 LONDON AIRPORT
Figure 6 . 1
ACCIDENT TO B.E.A.C. VISCOUNT G-AMOK ON 16-1-55
I1
PLAN Of N.W. AREA OF AIRPORT

-. RrmPDvrSKmQ~.
T A B D l D I C A I B ~
YNWHIQIIPAIIDPIUD.

Klkwmprm
T O ~ ~ ~ A U
BnwQNm9A2mw~
RUNWAY OR TAPWAY

A RV.%

--- C R W c + a a ~
T-AY LIQTn

m.LL---
e m - - - * - - -----
58 ICAO Circular - 5 0 - A ~ / 4 5
southeast of Dexter. Iowa. on 19 Janua
released 7 September 1955.
Circumstances
The flight departed Newark, NewJersey,
a t 0 7 0 3 Central Standard Time e n route to
Lincoln, Nebraska, with numerous interme
diate stops scheduled. Following departure
f r o m Des Moines a t 1 6 0 8 on a V F R (Visual
Flight ~ u l e s flight
) plan the a i r c r a f t climbed
to 5 0 0 0 feet whereupon the c r e w noticed
vibration and a slight fore-and-aft movement
of the control column. The climb was con-
tinued to 6 0 0 0 feet where the a i r c r a f t was
levelled off and power was reduced. The cap-
tain attempted to dampen the vibration by
engaging the autopilot, however, this proved
to be unsuccessful. The f i r s t officer lowered
the flaps to 15 degrees without any noticeable
effect. At this time a sudden failure in the
control s y s t e m was felt and i t was extremely
difficult to maintain any semblance of elevator
control. The buffeting continued to be s e v e r e
and the c r e w prepared for a n emergency land-
ing. Another failure in the control s y s t e m was
felt and the a i r c r a f t went into a steep climb.
As i t appeared that a stall was imminent the
captainmoved the propellers to a high r . p , m .
and pushed the throttles forward until about
50 inches of manifold p r e s s u r e was seen on the
gauges. The a i r c r a f t nosed over and went in-
to a steep dive. During the rapid descent the
captain reduced power and headed for open
country. At 5Q0 feet he succeeded in flaring
the a i r c r a f t and made a wheels-up landing on
the snow-covered ground. The c r e w of three
were uninjured, however, a few of the 36 pas-
s e n g e r s received m i n o r injuries.
Investigation and Evidence
Because of the nature of the accident,
attention was immediately directed to the
empennage and control system of the aircraft.
The empennage section was intact and virtually
undamaged by ground contact. During the
examination of the elevator torque tube assem-
bly it was observed that there was a vertical
f r a c t u r e of the right side. This completely
disconnected the right elevator f r o m the main
torque tube assembly* and the pilot could no
longer operate this elevator by means of the
No. 7
elevator control system. The left elevator was
s t i l l attached to the torque tube assembly, how-
e v e r , and partial elevator control could still be
effected.
-
The left elevator servo tab was found
hanging in the full down (nose-up) position, with
the r e a r terminal of the aft push-pull tube
attached to the tab horn. Internal inspection
of the servo tab a s s e m b l y revealed that this
push-pull tube had broken transversely about
12 inches forward of i t s r e a r terminal. The
r e a r portion of the broken tube showed evi -
dence of abrasion o v e r m o s t of i t s e x t e r i o r
surface, caused by i t s rapid and violent move-
ment within the elevator. The i n t e r i o r surface
of the elevator skin in the a r e a of the tab push-
pull rod was s e a r e d and abraided, and the skin
was punctured i n s e v e r a l places. The inspec-
tion doors were opened, and i t was found that
the s e r v o tab idler was completely detached
f r o m i t s support in the elevator. The 1/4 x
3-1/2 inch close tolerance support bolt was
f r a c t u r e d about one inch f r o m the head end and
this end of the bolt was found in the lower r e a r
flange of the stabilizer 2 0 inches outboard of
the idler. The remaining portion of the idler
r e a r s p a r support bolt was found in place in the
idler with i t s fractured end flush with the in-
board face of the idler; i t s broken end was
battered. A 1/4 inch castellated nut and two
washers of the size and type used with the
support bolt were recovered f r o m a fold in the
seal balance curtain. No cotter pin was found.
The hinge cutouts on the tab were torn r e a r -
ward, indicating t h e r e had been a violent
oscillation of the tab resulting in considerable
overtravel.
To understand better the chain of events
that occurred with r e s p e c t to work performed
on this a i r c r a f t , i t was advisable to examine
the line of command with redpect to personnel
a t the Newark base, and their working hours.
The base i s headed by a station manager, who
h a s under him a chief mechanic, supervisors
of mechanical s e r v i c e s (crew chiefs), inspec-
t o r s , lead mechanics, and mechanics. T h e r e
a r e three 8-hour shifts daily beginning a t
 ICAO Circula
-.c
12 midnight, with personnel reporting for duty
30 minutes before each shift. Top supervisory
personnel above the crew chief level a r e a
part of each shift o r a r e available by telephone
if needed.
The c a r d system used in the allocation
of work comprises a work control record, a
routine job c a r d , and a non routine job card.
The work control r e c o r d i s a m a s t e r c a r d
that lists all the work to be performed. Rou-
tine job c a r d s a r e distributed among the
mechanics according to the number of a r e a s
necessary to be covered for each individual
inspection. Nonroutine job c a r d s a r e made
out and initialed by mechanics when they en-
counter work necessary to be done other than
that specified on the routine job card.
The a i r c r a f t was in the shop ready for a
1500-hour check a t the s t a r t of the 8:00 a.m.
4:00 p. m. shift the morning of 18 January.
During the inspection of the empennage, which
involved a detailed inspection of the horizontal
stabilizer, elevator, and related control sys-
tem components, i t was found that there was
excessive play in the elevator servo tab. A
nonroutine job c a r d was made out by the me-
chanic but no corrective action was taken
because of the proximity of a shift change.
The c r e w chief going off duty briefed the crew
chief on the afternoon shift on the required
work. The c a r d indicating that repair of the
servo tab was necessary was then given to
another mechanic.
The idler linkage was disassembled to
determine the cause of the play and i t was
found that the idler support bolt was consider-
ably worn. The mechanic left the bolt with h i s
crew chief for examination and returned to h i s
work. This particular bolt was not in stock
and an emergency o r d e r was issued requesting
that i t be sent immediately f r o m the company's
base a t San Francisco. This emergency o r d e r
was written up on the nonroutine job card. The
mechanic later testified that the worn bolt was
returned to him by the lead mechanic with the
instruction to put i t back in the idler assembly
loosely (finger-tight). The worn bolt was then
replaced but not safetied. No explanation was
written on the nonroutine job c a r d covering
this temporary installation. This was contrary
to the company's maintenance instructions.
When the midnight shift came on duty
there was a heavy workload and the new crew
chief (who was the only one assigned on that
shift - normally there a r e two) was not brief-
ed with respect to the worn bolt.
The work on the a i r c r a f t continued in a
normal manner and when completed the super-
visor noticed that the subject nonroutine job
c a r d had not been signed off a s completed. At
this time, however, the mechanic assigned to
the job reported to the supervisor that he could
not find any excessive play in the servo tab
assembly. Accordingly, a n inspector was
requested to check and determine i f this was
so. He returned in a s h o r t time and s a i d that
he also could find none. The supervisor then
went to the job with the inspector and f r o m the
ground watched while the tab was checked f o r
f r e e play. Observing no excessive play the
supervisor initialed the nonroutine c a r d , adding
the notation "OK f o r service. "
Correlation of known physical facts with
c r e w testimony indicates the following sequence
of failure. The unkeyed castellated nut which
- fastens the idler assembly support bolt in i t s
brackets backed off because of vibration. This
permitted the bolt to come out of the outboard
bracket. With the idler supported only by the
bolt through the inboard bracket, f o r c e s were
exerted which broke the bolt one inch f r o m i t s
head. This allowed the i d l e r to drop down and
the servo tab began to oscillate, causing a for-
ward and r e a r w a r d movement of the cockp$t
control column. Loads were then induced in
the r e a r push-pull tube causing i t to fail. With
the then unrestrained tab oscillating, the left
elevator was also affected s o that i t , too,
oscillated about i t s hinge line, The resultant
loads caused by the left and right elevators
being out of phase broke the right side torque
tube connector plate, eliminating the right
support f o r the torque tube assembly and pre-
venting cockpit control of the right elevator.
Without the right support, f o r c e s deformed the
torque tube assembly forward about the left
support, resulting in almost negligible control
of the left elevator f r o m the cockpit.
During the investigation of this accident,
a thorough study was made of the company's
line maintenance procedures, encompassing
i t s record control system. It was determined
that the c a r r i e r ' s m a i d e n a n c e programme and
detailed procedures set up to i t were adequate.
However, the procedures broke down due to
the frailties of the human element. The s y s t e m
provided safqguards, ane of which required
that a n txvlanation of all work performed be
written on the respective nonroutine job c a r d ;
ano'ther that the outgoing c r e w chief a t the time
of the work shift brief, in a s much detail a s
necessary, the relieving c r e w chief concerning
the work accomplished during the foregoing
work period. In this case, these procedures
were not followed.
60 C i r c u l a t 50-&/45
I ~ A O
When the final inspection f o r play in the
servo tab was made, no excessive play was
found. It was testified to, that i f the worn
support bolt was replaced and by chance turn-
ed f r o m i t s position when removed, a manual
t e s t f o r play might r e s u l t in none being found.
However, since the nonroutine job c a r d was
written up for work to be done and was not
signed by the mechanic to indicate that the
work had been accomplished, i t i s believed
that the inspector making the final inspection
should have gone beyond the normal instruc-
tions and actually examined the servo tab sys-
tem. If this had been done the mistake proba-
bly would have been discovered before the
mechanic was told to close a l l inspection covers
ICAO Ref: AR/391
and doors. The c r i t i c a l omission was the fail-
ure to write an explanation on the job c a r d that
the bolt had been removed and replaced only
finger-tight pending the a r r i v a l of a new bolt.
As a result of this accident the company
h a s increased the number of both supervisory
personnel and mechanics.
Probable Cause
The probable cause of this accident was
a s e r i e s of omissions made by maintenance
personnel during a scheduled inspection which
resulted in the release of the a i r c r a f t in a n
unairworthy condition and an almost complete
l o s s of elevator control during flight.
 ICAO Circular 5 0 - ~ N / 4 5 61

-
No. 8

Indian Airlines Corporation, Douglas DC-3, VT-COZ a i r c r a f t ,

crashed near Gauhati Airport, India, on 21 January 1955.
Report dated 23 March 1955 released by Ministry of
Communications, Cove rnment of India.

Circumstances P r e s e n t weather Fog, become thinner

P a s t weather Fog
The aircriift took off f r o m Calcutta (Dum Significant cloud F i r s t layer Second layer
Durn) on a scheduled freighter service flight a t Amount of cloud 1 Octa, 3 Octa.
0546 hours Indian Standard Time and s e t course Type of cloud
for Gauhati, carrying a c r e w of three. At Height of base
St.
500
. Ac
10,000~
0722 hours, the a i r c r a f t contacted Air Traffic QFE 29.89"
Control, Gauhati, on radio telephony and re- Altimeter setting QNH 30.0611
ported flying under visual flight rules, 25 miles
away f r o m Gauhati Airport at an altitude of A special weather observation was made
6 000 feet. The Air Traffic Control Officer on a t 0715 hours a t the request of the aerodrome
duty passed the altimeter setting to the aircraft, control. Visibility had improved to 1.5 nautical
cleared i t to descend under VFR and instructed m i l e s
it to call when ten miles f r o m the a i r p o r t . The
.
aircraft asked f o r a bearing on frequency 119.7 The a i r c r a f t c r a s h e d a t a distance of
(Homer) a t 0725 hours and a bearing of 045O 2.9 miles on a bearing of 2100 f r o m the 03 end
class llA1lwas given. This was confirmed a s bf runway 03/21 a t Gauhati a i r p o r t a t an eleva-
c o r r e c t by the a i r c r a f t , which a l s o reported tion of 162 feet a.m. s, 1,
being 15 miles f r o m the a i r p o r t a t a height of
3 000 feet a t that time. The next contact with The engine control pedestal was exten-
Gauhati Tower was a t 0727 hours when i t sively damaged and no reliance could be placed
reported being a t a distance of 10 miles f r o m on the position of the l e v e r s , which were a s
the airport. Landing instructions were passed follows:-
to the a i r c r a f t and i t was asked to call again
on joining circuit. T h e r e was no further com- Left hand Right hand
munication with the a i r c r a f t . At approximately
0729 the duty officer a t the tower noticed black Mixture controls Auto-lean E m e rgency
smoke a t the top of a patch of fog to the south Throttles Retarded Retarded
of the airport. Repeated c a l l s were made to Propeller P i t c h Fully Fully
the a i r c r a f t on 118.1 MC/S and 6 440 KC/S but controls coarse coarse
no response was received. At about the s a m e
time persons in Tarapati village saw the a i r - The position of the fuel selector and the
c r a f t hit some arecanut t r e e s , c r a s h in a field cross-feed could not be determined, but the
and b u r s t into flames. The captain and co- positions of the t r i m m e r controls were a s
pilot died instantly and the radio officer died follows:-
en route to the hospital. The a i r c r a f t was
destroyed. Elevator t r i m 1' nose down
Rudder t r i m Zero
Investigation and Evidence Aileron l o right up
The c r a s h a r e a was covered by fog a t the The actual settings of the tabs on the
time of the accident. The exact height of the elevator and rudder were 1/211 up and full to
fog could not be accurately established but was the left respecfively. The aileron t r i m tab was
estimated to be about 250 to 300 feet above neutral. The control cables were checked.
ground level. They showed evidence of tensile f a i l u r e only a s
a r e s u l t of disintegration of the a i r c r a f t .
The 0700 weather observation was a s
follows: Pilot's a l t i m e t e r was s e t a t 29.8611,
The sub-scale of the second a l t i m e t e r was m i s s -
Total amount of cloud 4 Octa ing.
Visibility 0.9 nautical miles
62 ICAO Circl
The undercarriage of the a i r c r a f t was
down and locked.
There was no evidence of any mechanic-
a l failure of the engines. Both the engines
were clear of any sign of f i r e , external o r
internal. There was evideqce of adequate
lubrication. F u e l was recovered f r o m the
nacelle f i l t e r s and injectors. Both the pro-
pellers were in the constant speed range and
in the s a m e fine pitch.
The a i r traffic control and communica-
tion briefing for the flight was of a routine
nature. However, some special significance
attaches to the meteorological briefing. The
meteorological forecast covering the route
along with the terminal forecast f o r the period
0630 hours to 1030 hours for Gauhati Airport
was handed over to the captain, the Commander
of the aircraft. The terminal forecast indi-
cated surface visibility of 660 y a r d s i n fog,
intermittently 110 yards in thick fog, up to
0830 hours and thereafter improving to five
nautical miles. It may be pointed out that the
weather minima laid down f o r Gauhati Air-
port by the Indian Airlines Corporation and
approved by the Director General of Civil
Aviation require a visibility of 1.5 nautical
miles f o r landing by day, The alternate aero-
drome specified in the clearance f o r m was
Agartala. Nevertheless, the forecast did not
contain the terminal f a r e c a s t for the alternate.
The captain did not a s k f o r this information,
nor did the meteorologist volunteer this infor-
mation during the briefing.
Notice to Airmen No. 29 of 1952 which
lays down Meteorological Minima for Aero-
dromes, requires that "a flight shall not be
continued towards the aerodrome of intended
landing unless the l a t e s t available mdeorolog-
ical information indicates that conditions a t
that aerodrome, o r a t least one alternate
aerodrome, will, a t the expected time of
...
a r r i v a l , be a t o r above the minimum c r i t e r i a
specified f o r such aerodromes
c a s e , although the terminal forecast for
In this
Gauhati indicated that the conditions of visibil-
ity would be lower than the minima for land-
ing by day, and no terminal forecast w a s
available to the pilot for any alternate f o r the
expected time of a r r i v a l , the flight took off
and continued to Gauhati, contrary to the
provisions laid down in the above Notice to
Airmen.
It is relevant to add that the weather
observation made a t 0500 hours at Gauhati
indicated a visibility of 550 yards in thickening
fog. As a result of this, a n M.5 (Danger Met.)
for visibility was issued by Gauhati. This
message did not reach Air Traffic Control,
Calcutta, until 0700 hours and, therefore, was
not passed on to the aircraft.
It would seem, therefore, that the a i r -
c r a f t should not have taken off for Gauhati in
view of the terminal weather f o r e c a s t for that
a i r p o r t and that the flight should not have been
continued.
The a i r c r a f t had i t s f i r s t impact with
arecanut t r e e s , 43 feet above' the ground. The
nature of the cuts on these t r e e s indicated that
the a i r c r a f t was in a laterally level attitude.
The a i r c r a f t had i t s second impact, 100 feet
ahead, with a bunch of t r e e s , 40 feet above the
ground. This goes to show that within the
distance of 100 feet (the distance between the
points of the two impacts) the a i r c r a f t lost
three feet in height. The p o r t wing tip w a s t o m
off a t the f i r s t impact. The second impact
caused pieces of landing light glass, cockpit
glass, engine nacelle p a r t s , a section of the
p o r t elevator with fabric and p a r t of the port
aileron to be thrown off f r o m the aircraft. Yet
the a i r c r a f t continued in the a i r until i t hit the
ground a t a distance of 830 feet f r o m the point
of initial impact. At the time of the c r a s h with
the ground, the a i r c r a f t was substantially level
laterally, though in a nose-down attitude.
Heavy disruption of the a i r c r a f t took place a t
this point.
None of the components picked up between
the points of the f i r s t and second impacts suf-
fered any damage f r o m f i r e o r smoke. Similarly,
a l l the components picked up in the vicinity of
the point where the a i r c r a f t hit the ground were
completely f r e e f r o m any evidence of f i r e o r
smoke. In fact, it was not until another 230 feet
away f r o m this point that the f i r s t burnt compo'
nent (part of port aileron) was found. This
component was laying within 12 yards of the
burnt and burst port main fuel tank. Several
components, such a s the main cargo door, sec-
tions of the port elevator and floor board, which
had been separated f r o m the a i r c r a f t on i t s dis-
ruption, were also c l e a r of any f i r e o r smoke.
L a r g e r pieces of wreckage (the starboard
wing centre section and r e a r ?uselage) had
suffered damage by f i r e , but i t had affected the
top surfaces only. The fabric of the rudder and
the elevators, which were still attached to the
respective stabilizers, was burnt, but not the
sections of the port elevator which had been
torn off e a r l i e r . There was no evidence of f i r e
on the lower surfaces of the starboard wing o r
the horizontal stabilizers. There was no smoke
trail on either side of the fuselage. There was
no soot or f i r e t r a i l running f r o m the sides of
the fuselage to the attachment of the stabilizers.
The maximum intensity of the f i r e had been in
the a r e a of the cabin opposite the freight doors,
The doors together with the f r a m e s had, how-
ever, been thrown off e a r l i e r and were perfect-
ly clean. P i e c e s of floor board f r o m this a r e a
had also been thrown out. A piece of floor
board in the immediate a r e a of the burnt fuse-
lage was c h a r r e d , and yet the two adjoining
pieces of floor boards which were thrown c l e a r
of fire were untouched by f i r e o r smoke. The
a i r c r a f t step-ladder, which is normally placed
in this region, but was thrown out on impact,
was also c l e a r .
F r o m the foregoing data, i t is evident
that there was no f i r e in the a i r c r a f t either a t
the point of i t s f i r s t impact with the arecanut
t r e e s o r even when the a i r c r a f t hit the ground
at a distance of 830 feet f r o m this point. The
fire obviously started approximately 230 feet
from the point where the a i r c r a f t hit the ground
(approximately 1 060 feet f r o m the point of
first impact), a s a result of the bursting of
the port main fuel tank.
The theory that a f i r e took place in the
a i r c r a f t during flight was advanced by some
witnesses. This theory was given careful
consideration but found to be untenable. The
examination of the wreckage definitely reveal-
ed that f i r e broke out in the a i r c r a f t after i t
crashed against the ground. The theory of f i r e
during flight was chiefly built up on a rumour
that the a i r c r a f t had, just before i t crashed,
sent an S. O.S. signal. It was established that
no S.O.S. signal was sent by the a i r c r a f t . The
mistake a r o s e because a signal sent by Air
Traffic Control, Gauhati, to Air Traffic Con-
trol, Calcutta, was misunderstood by the
Operations staff of Indian Airlines Corpora-
tion to whom i t was read out on the telephone.
The signal r e a d a s follows:-
"QBM VTCT = LAST QSO VT-COZ 0 157
Z (.) SMOKE SEEN THEREAFTER (.)
OFFICERS GONE OUT TO ASSESS
NEWS ( . ) I t
The word Itassess1'was misheard for
S. 0. S.
The C 0 2 fire extinguisher bottle a s well
a s two f i r e extinguishers were recovered f r o m
the scene of the wreckage. The head of the
CO2 bottle had broken off and i t was empty.
The head of one of the extinguishers was a l s o
broken and i t was partially empty. The second
bottle had i t s handle loose and was empty.
Examination of the wreckage revealed that
a t the time of the c r a s h the undercarriage of
the a i r c r a f t was down and locked and both
engines were operating. The a i r c r a f t was in
a laterally level attitude and lined up with the
runway. These f a c t o r s go to show that the
a i r c r a f t was attempting a controlled descent
on the runway a t Gauhati A i r p o r t and did not
come down on account of any d i s t r e s s o r e m e r -
gent y. The l a s t communication between the
a i r c r a f t and the Air Traffic Control, Gauhati,
had been exchanged just two minutes p r i o r to
the accident. At the time of the c r a s h , con-
siderable fog hung over the a r e a southwest of
the a i r p o r t - the direction f r o m which the air-
c r a f t was approaching. The a i r p o r t itself and
an a r e a of about two miles to the southwest
were, however, c l e a r . The fog was beginning
to f o r m into s t r a t u s cloud and the tops were
estimated to be approximately 300 feet above
ground level. As the sky above the cloud was
c l e a r , the pilot m u s t have seen the a i r p o r t
f r o m some distance when still a t a height, and
apparently he decided to make a straight-in-
approach to land, a practice frequently follow-
e d by pilots arriving a t Gauhati Airport f r o m
Calcutta. This i s c l e a r f r o m the fact that the
a i r c r a f t was accurately lined up with the run-
way with wheels down. There i s no doubt that
the pilot was making a controlled descent and
entered the fog expecting to get out into the
c l e a r on the other side which he had e a r l i e r
seen and known to be c l e a r . Indeed he would
have been able to do so, had the a i r c r a f t main-
tained sufficient height.
It was not possible to a s c e r t a i n the reason
why the a i r c r a f t was s o much lower than it
should have been, but i t is almost certain that
the pilot himself was not aware that he was so
low over the ground. The two possible expla-
nations a r e that either the pilot did not observe
the altimeter o r the altimeter itself may not
have been s e t c o r r e c t l y and did not indicate
c o r r e c t height. It may be added that the a i r -
c r a f t radio log book was missing even though
a l l other documents were recovered f r o m the
wreckage. T h e r e was no f i r e in thz a r e a occu-
pied by the radio officer, although considerable
disintegration had taken place. This log book
would have disclosed what e n t r i e s had been
made therein regarding the altimeter setting.
64 ICAO Circular 5 0 - ~ ~ / 4 5
Probable Cause
The a i r c r a f t crashed in the course of a
premature descent, during the final approach,
a s a result of hitting arecanut t r e e s which
were obscurred f r o m view by fog in the a r e a .
Recommendation
There a r e reasons to believe that the
premature descent of the a i r c r a f t was due to
the pilot's' being unaware of h i s c o r r e c t alti-
tude when entering the fog. Such a situation
could easily a r i s e f r o m either a n incorrect
setting of the altimeter o r the pilot's failure
to observe i t a t the time. It is, therefore,
recommended that pilots should be warned
against the recurrence of such a happening,
and should, in o r d e r to avoid e r r o r s , be
required to repeat the altimeter setting to the
Air Traffic Control.
ICAO Ref: AR/403
Observations
Some other points which c a l l for observa-
tions havs come out in the course of the
evidence and though they do not directly pertain
to the cause of this accident a r e well worth
mentioning.
i) Operational control was not exercised
for this flight and the operator hadnot
designated a representative for this
purpose a s required by Notice to Air-
men No. 29 of 1952.
ii) The meteorological briefing of the
pilot was not complete in a s much a s
the terminal weather forecast for the
alternate aerodrome was not obtain-
ed by him.
iii) The manuals used by the c r e w of this
a i r c r a f t were not complete o r up-to-
date.
 ICAO Circular 50-AN/45
t
No. 9
Circumstances
The flight, a scheduled night airmail and
p s s e n g e r flight operating on the Nagpur-Delhi
lector of the night airmail network, took off
from Nagpur Airport at 0348 hours Indian Stand-
*rd Time carrying s i x passengers and a crew of
four, After the aircraft became airborne it was
reen climbing steadily, then it turned to port
and disappeared f r o m view. Immediately there-
after, the duty officer, Air Traffic Control, at
Nagpur saw a huge flash, followed by a wide-
apread f i r e in the direction in which the aircraft
was last seen, He attempted to establish contact
with the aircraft by calling it on radio-telephony
but no response was received, so he then sounded
the crash siren. At about the same time some
persons in the neighbourhood saw the aircraft
come down and crash at approximately 0350 hours
in a field. It disintegrated, burst into flames
and was completely destroyed. There were no
survivors.
Investigation and Evidence
At the time of the accident, weather con-
ditions were a s follows:
Clouds Nil
Visibility 5 nautical miles
Wind 050 "/4 knots
Aerodrome barometric
pressure 974.7 mbs.
Temperature and humidity 63 O F . 75%
The aircraft crashed at a distance of 5 650
feet on a bearing of 196' from the 09 end of Run-
way 27/09 a t an elevation of 1 000 feet a.m. s. 1.
(the elevation of Nagpur Airport i s 1 020 feet).
The wreckage trail was on a heading of 58 degrees
and 672 feet in length. It showed that the aircraft
f i r s t hit the ground with the port wing tip. Pieces
of red glass from the port navigation light were
picked up a t this point. As a result of the f i r s t
impact with the ground, and a subsequent impact
further inboard on the wing tip, a section of the
port wing tip was torn off. The aircraft then
levelled laterally, but was in a steep nose down
attitude when it hit the ground with the propeller
rotating at a considerable speed. The drag occa-
sioned by the impact of the port propeller and
port nacelle with the ground caused the aircraft
65
to slew around about 90' and, in that position,
be hurled forward by sheer momentum. The
distance between the point of major impact and
the end of the wreckage t r a i l was 544 feet.
This indicates that the aircraft must have hit
the ground at a high speed.
The t r a i l of f i r e commenced a t the point
of impact of the nose with the ground. The
heavy impact disrupted some of the fuel tanks
and pipe lines causing f i r e to break out and
general disruption of the aircraft started to
take place between 100 and 200 feet of the f i r s t
heavy impact. The port wing was hurled 140
feet to the left of the wreckage trail and the
fuselage, except the nose section, separated
itself from the centre section, and then hurtled
forward until i t hit two trees. Dut to hitting
the t r e e s i t s tail was torn off while the remain-
ing section continued to move forward and
finally came to r e s t 530 feet down the trail.
The port engine was hurled to a point 672 feet
distant from the point of f i r s t impact and the
starboard engine came to r e s t 477 feet down
the wreckage trail.
The following points emerged after exam-
ination of the wreckage:
1) The propeller domes were removed
and indicated that they were both in
the constant speed range and at a
setting of 26 '.
2) No reliable settings of the engine
controls could be determined.
3) The engine and flight instruments
were crushed and destroyed, and the
rudder and aileron trimmer settings
were unreliable, although the elevator
indications showed a 'neutral1 trim.
The altimeter settings were 28.78"
and 29.84". Both the direction gyro
and the artificial horizon were destroy-
ed except for the casing with the knobs
which were in the caged position. The
possibility of the pilot having taken off
with these instruments caged cannot
be ruled out. The ignition master and
individual magneto switches were f r e e
to swivel, but were picked up in the
"all-on" position.
66 ICAO Circular 5 0 - ~ ~ / 4 5
4) The undercarriage and flaps were both
fully retracted.
5) No evidence was found of the aircraft
having struck any object prior to i t s
hitting the ground.
6) The control cable runs were satisfac-
tory. Cables had failed in tension
following the crash.
7) There was no evidence of any explosion
having occurred in the air.
8) The port and starboard engines were
torn off f r o m the mountings. The star-
board engine was still substantially
intact although the accessories suffered
damage, The port engine auxiliary
section separated f r o m the power sec-
tion. Neither of the two engines showed
any signs of external o r internal fire.
Partial dismantling of the engines show-
ed evidence of adequate lubrication.
Neither of the propellers was feathered
and both were at the same fine pitch
setting.
9) With the exception of the port wing and
i t s corresponding section of flaps,
practically a l l other components show-
ed evidence of heat. Although there
was evidence of a light smoke t r a i l on
the lower surface of the centre section
directly behind the starboard wheel
well, there was marked absence of
smoke in the a r e a immediately behind
the partially opened inspection panel
situated in the very heart of this loca-
tion. As this inspection panel had evi-
dently opened after the buckling of the
skin on impact of the aircraft with the
ground, i t showed that the t r a i l was
formed after the disruption of the fuel
tanks and when the aircraft hurtled
forward on i t s own momentum.
10) There was no sign of any control, me-
chanical o r structural failure.
11) There was no sign of any f i r e having
broken out either in the engines o r in
the a i r f r a m e before the disruption of
the fuel tanks on impact with the ground.
The aircraft had commenced i t s flight
a t Madras a t 2300 hours on 1 February 1955 and
landed a t Nagpur a t 0230 hours on 2 February
1955. The flight f r o m Madras to Nagpur had
been uneventful, however, the smell of battery
fumes was noted and the unserviceability of the
radio cofnpass. On a r r i v a l at Nagpur the bat-
t e r i e s were checked and when the radio compass
proved to be unserviceable an overhauled unit
was obtained and installed.
The commander of the Dakota possessed
a total of 5 867 hours 40 minutes flying experi-
ence. As day commander he had 2 533 hours
to his credit but a s night commanddr his expc-
rience amounted to only 245 hours 15 minutes.
The co-pilot had a total flying experience
of 3 671 hours 50 minutes and had no experience
a s a night commander. As night co-pilot he had
268 hours 30 minutes to his credit.
The engines suffered no damage by f i r e
internally o r externally. The removal of filters
and partial dismantling revealed no evidence of
mechanical failure. The port propeller had cut
into the ground when rotating at high speed, and
the starboard propeller had cut the ground par-
allel to the wreckage t r a i l a f t e r the a i r c r a f t
slewed at right angles to i t s direction of motion.
These factors coupled with the fact that both
propellers were at the same fine pitch setting
and neither of them was feathered, indicate
that the engines were in operation at the time
the aircraft made i t s f i r s t impact with the ground.
One significant feature which emerges
f r o m the examination of the location of the
wreckage i s that the aircraft must have been in
a steep turn soon after take-off. The aircraft
got the clearance f o r take-off a t 0348 hours and
commenced i t s take-off run immediately. After
the.aircraft was airborne, i t turned to port.
There was no direct evidence regarding the na-
ture of the turn, but if one takes into account
the time factor, the location of the wreckage
and the fact that the wreckage t r a i l was on a
heading of 58 degrees, there i s no doubt that
the aircraft took a steep turn to port at a low
altitude. During this manoeuvre, the aircraft
lost height and slipped into the ground. This is
confirmed by the fact that the aircraft f i r s t hit
the ground with the port wing tip a t an angle of
42 degrees.
 ICAO Circular 5 0 - m / 4 5
-
No importance need be attached to the
fact that the captain took a turn to the left instead
of to the right, a s i s generally done by most of
the pilots when taking off for Delhi f r o m Runway
27. We find f r o m the record that i t was not un-
usual for the pilot in question to take a turn to
the left but the mistake lay in badly executing a
turn.
The reason f o r such a steep turn i s not
easy to ascertain. It i s possible that the pilot
may have done s o in o r d e r t o get on course quick-
ly. It i s also possible that he relied on visual
reference instead of flying entirely on instruments
a s he should have done, thereby going into a turn
steeper than intended, o r i t may be that he was
misled by the instruments.
Probable Cause
3) The pamphlet "A Survey of Accidents to
The a i r c r a f t crashed a s a result of slipping
into the ground in the course of a badly executed
steep turn to port c a r r i e d out a t night a t a low
altitude.
Recommendations
1 ) Although under the present regulations,
licensing of commerclaI pilots includes
instrument flying, it i s recommended
ICAO Ref: A R / ~ O ~
67
that Instrument Rating according to
ICAO standards should be made a com-
pulsory requirement for pilots engaged
in commercial a i r transportation. All
flights operated during the night a r e to
be treated as flights under Instrument
Flight Rules, a s recommended in the
Regional Supplementary Procedures
issued by ICAO (See Doc. 7030) and
r e f e r r e d to in Notice to Airmen No. 2 3
of 1952.
Operators should be required to make
compr ehansive and up-to-date Opera-
tions and Maintenance Manuals available
for the use of a i r crews and other tech-
nical personnel engaged in scheduled a i r
transport services.
Indian Registered Aircraftt1, which a t
present i s published annually, i s a use-
ful document. It is recommended that
full details pertaining to the cause of
each accident, along with such instruc-
tions and advice a s m a y be considered
necessary to prevent similar accidents,
should be circulated immediately on
completion of investigation to a l l a i r
crews, engineers and others concerned.
68 ICAO Circular 5 0 - ~ ~ / 4 5
No. 10
SABENA (SocibtC Anonyme Belge _dlExploitation de l a Navigation ACrienne),
-
DC-6 a i -.
r c r a f t , 00-SDB,
----- crashed a t Costone dell'Acquasanta,
Reatini Moy_"gns, on 17 February 1955.
Report by Ministerlo Difesa Aeronautics, Italy.
Circumstances
The a i r c r a f t departed the Brussels-
Haren airport f o r Rome a t 1617 hours Green-
wich Mean Time on a n IFR flight plan, hccord-
ing to radio communications between the a i r -
craft and the a r e a controls a t Zurich, Milan
and Rome the flight appears to have been n o r m -
al. The a i r c r a f t was in touch with Rome a r e a
control a t 1829 hours and the l a s t message
f r o m i t was received a t 1853 hours. At about
1850 GMT the a i r c r a f t after overflying the
village of Leonessa continued in flight on a
heading of 163 degrees until it hit the slope of
the Costone dellIAcquasanta a t a height of 1 700
metres, after breaking off the tops of t r e e s in
a wood in line with the point of impact, near
the end of i t s course. There were no survi-
vors among the 8 crew members and 21 passen-
g e r s on board.
Investigation and Evidence
The weather situation in general was a s
follows: anticyclone over the North Atlantic
with a large a r e a of low p r e s s u r e f r o m the
Baltic to the Central-Western Mediterranean.
The low was over the Gulf of Genoa and extend-
ed to the Central Tyrrhenian. In addition,
there was a disturbance produced by the influx
of cold masses originating in the Atlantic,
meeting with pre-existing w a r m and very
humid masses.
At 1800 GMT, the cold front of the above
disturbance, which had been detected previously
lay along the line f r o m the Strait of Bonifacio to
Ortebello and Perugia, and a t 2100 GMT, this
front must have been on the a i r c r a f t ' s route in
the vicinity of Viterbo.
The evidence gathered f r o m the weather
charts and f r o m the testimony of the inhabitants
of Leonessa (closest inhabited centre t o the
scene of the crash) indicates that clouds were
generally stratified apd accompanied by moder-
ate rain and snowfall. Cloud base varied f r o m
400 to 750 metres; cloud top varied f r o m 3 500
to 4 000 metres in the prefrontal zone, but may
have been over 5 000 to 5 500 m e t r e s (16 500 t o
#
18 100 feet) in the postfrontal zone. No mete-
orological phenomenon was reported by the
stations in Latium and Tuscany o r by a i r c r a f t
in flight, either before o r after the time con-
sideled. Such a n assumption would imply an
isolated phenomenon, which i s not c ~ n f i r m e d
by the facts ascertained in situ.
The o 0 C isotherm in the prefrontal
zone was a t 2 200 m (Ciampino sounding a t
1400 GMT on 13/2/55) and fell in the postfron-
tal zone to 1 600 - 1 800 m (Ciampino sounding
a t 0200 GMT on 14/2/55).
Wind analysis by altitude gives the fol-
lowing table :
P r z o n t a l zone l ) o s t T F o ~ n e
( Rome - Viterbo) (Viterbo -Florence)
5,000 ft. 240'- 25 kt. 290'- 25 kt.
10,000 ft. 290°- 35 - 40 kt. 2 9 0 9 35 kt.
18,000 ft. -- 80 - 85 kt. 2 8 0 9 75 -80 kt.
270°- A
It should be pointed out that the informa-
tion and forecasts supplied to the pilot a r e in-
f e r r e d , a s regards high altitude winds, f r o m
the observations taken a t 0200 GMT on 13/2.
The chief meteorologist a t the aerodrome of
departure hastened to communicate later de-
tails on high altitude winds, following receipt
of information f r o m a crew which had flown
the route in the opposite direction a short time
before the departure of the a i r c r a f t 00-SDB.
Reports f r o m various sources confirm
the presence of strong winds a t 75 - 90 knots
f r o m the West, stronger than forecast. It may
further be assumed that on the Apennine c r e s t ,
i . e., along the a i r c r a f t l s route, the velocity of
crosswind must have increased by Venturi
effect.
Position reports relatingito the naviga-
tion of a USAF-Navy aircraft, which flew the
section of advisory route 512 ( ~ r e n n e -
r Padua -
-
Lugo - Viterbo Civitavecchia) involving the
Apennine region north of Rome, a t about 1930
GMT, indicate a navigation t i m e of 38 m 30 sec.
between Viterbo NDB and Civitavecchia NDB.
 ICAO Circular
Such a value i s obviously impossible, in
d e w of the small distance between the NDBIs
bvolved (26 nautical miles) and one i s led to
a e conclusion that during navigation over the
~ p n n i n esection, the a i r c r a f t must have en-
countered an unexpected and very strong wind
from the western sector, which c a r r i e d i t f a r
to the East of the 1)advisor route and led to
an e r r o r (probably not picked up) in position
over Viterbo NDB, and that this ex-
plains the transit time reported.
This deduction supports the conclusions
of a n analytical study by the Meteorological
Service pointing to the existence of a West-
East jet s t r e a m which must have influenced the
of the a i r c r a f t , causing a d r i f t of
greater extent than that taken into account by
the crew on the basis of the flight plan data.
On the basis of analysis of individual
thermodynamic soundings and of the presence
of an active frontal system, with thick and ex-
tensive cloud, it was concluded that there may
have been moderate to s e v e r e icing in the a r e a
between Florence and Rome, particularly a t
levels between 2 500 and 5 000 metres.
It i s not considered, however, that the
navigation of the a i r c r a f t was influenced by
icing, the more so a s there i s no corroboration
for this view in the reports of other a i r c r a f t
flying the same route about the time of the
accident.
Because the flight log and the radio log
were not recovered, the investigation concern-
ing the radio aids used by the a i r c r a f t had to be
restricted to consideration of the communica-
tions exchanged between the a i r c r a f t and the
ACCts a t Zurich, Milano (Linate) and Rome
(Ciampino) and to examination of the radio equip-
ment salvaged f r o m the wreckage.
It i s apparent f r o m the air-ground commu-
nications log that the a i r c r a f t regularly sent the
prescribed position messages over the various
beacons on Swiss and Italian Wts, without re-
porting difficulty o r malfunctionin8 of the a i r c r a f t
equipment o r complaining of lack of effectiveness
of the aids used.
The laboratory investigation on the radio
compass points to the conclusion that in all prob-
ability the two ADF receivers were set to the
radio beacons a t Civitavecchia (345 KC/S) and
Translator's Note: In Italian "assisted routetf. In Italy there a r e no advisory a r e a s o r routes
within the ICAO meaning of the terms. There a r e "assisted routes and a r e a s " the rules apply-
ing thereto differing from those for the advisory service. (See Buiatte, Termincllooia Aeronau-
tics, page 2, ICAO Library Ref. 453 B-932).
Rome Town (265 Kc/s), while the radio range
receiver was s e t to the Ciampino radio range
(255 KC/S).
It should be observed that weather condi-
tions were particularly unfavourable f o r the
use of medium frequencies.
This i s corroborated by the r e p o r t s filed
by the pilots-in-command of a i r c r a f t in flight
during the s a m e period, which mention diffi-
culties in reception f r o m radio beacons on
medium frequencies.
Difficulty in receiving f r o m radio beacons
was l a t e r confirmed by the navigation report of
the USAF-Navy a i r c r a f t previously mentioned
and by the inquiry by a i r c r a f t 00-SDB itself,
at 1848 GMT, a s to whether the Viterbo radio
beacon was operating a t full power.
A few s m a l l pieces (crew seat cushions)
found burnt near the engines indicate a very
limited post-crash f i r e in the vicinity of the
engines.
It may be inferred that the f i r e fighting
equipment was not used
a) because the accident must have
been unexpected, and,
b) because some of the c 0 2 extin-
guishers found among the wreck-
age were still charged.
There were no eyewitnesses t o the acci-
. dent. The location of the accident i s uninhabit-
ed, inaccessible and invisible f r o m any inhabit-
ed place o r road within a radius of about 15 k m
in a straight line. At the time of the accident
(1853 GMT) night had already fallen, it was
windy and raining and there was no f i r e visible
f r o m a distance.
A large part of the wreckage was discov-
e r e d in the vicinity of Point A in Figure 7.
Many p a r t s and fragments were found n e a r the
rocky spur (see Figure 7) and in the meadow,
not f a r f r o m the precipitous slope to the right
of the fuselage (viewed f r o m the r e a r ) .
The state of the wreckage confirms that
all forward and under parts of the a i r c r a f t
struck the rock face violently; to wit:
70 ICAO Circula
- the lower portion of the fuselage was
split open a t about the level of the
cabin floor;
- the wing and i t s appendages were re-
duced t o f r a g m e n t s , s o m e of extreme-
ly s m a l l s i z e , with the exception of
about t h r e e m e t r e s of the right wing
tip discovered n e a r the rocky s p u r ;
- the propeller blades were not twisted,
but w e r e n e a r l y a l l broken off a t the
hub o r reduced t o broken fragments
which b e a r witness to a n impact a t
full power.
The fuselage broke up into t h r e e p a r t s
presumably a t the v e r y second of impact upon
the slope. The engine cradles were torn f r o m
their moorings. In the engines s o m e cylinders
were wrenched off, casings cracked and in some a s he had not contacted that station, and r e -
c a s e s the reduction gear was torn away and the
corresponding cowlings were twisted, fragmen-
t a r y and widely s c a t t e r e d .
The wings were shattered into s m a l l
pieces, except n e a r the landing g e a r , to which
portions of the s p a r s remained attached, and
except the piece of the right wing tip,
The cockpit suffered g r e a t e r damage than
the r e s t of the fuselage a s i t i s situated in that
p a r t of the a i r c r a f t which sustained the f i r s t and
most violent shock. Nevertheless, the instru-
ment panel was in relatively good condition,
with a l l the instruments in place and some with
the g l a s s s t i l l intact. Many windows were un-
broken and the emergency exits in the usual
position a s apparently no attempt had been
made to use them.
The technical examination of the wreckage made in the proper manner and on schedule a s
and the inspection of the surrounding t e r r a i n
produced no evidence of any defect in the a i r -
c r a f t before the accident.
Technical examination of the radio equip-
ment gave the following r e s u l t s :
- the ADF r e c e i v e r was tuned to the f r e -
quency of 350 KC/S (corresponding to
the Civitavecchia NDB);
- the ADF receiver was tuned to the f r e -
quency of 261 Kc/s (corresponding t o
Rome Town NDB) ;
- the RNG receiver control box was tuned
to 225 KC/S (corresponding to Ciampino
range).
The VHF units had suffered too much
damage t o allow identification of the frequen-
c i e s to which they were s e t a t the time of the
c r a s h . However, contact with Ciampino con-
t r o l had been regularly established. on 119.3
MC/s .
A study of the r a d ~ om e s s a g e s exchanged
between the a i r c r a f t and the a r e a controls a t
Zurich, Milan and Rome brings out the follow-
ing basic points:
Contact with Zurich control
The operator had no VHF contact with
Monaco. At 1715 GMT he sent a radio-teleg-
raphy message over the frequency of 3,481.5/
3,478.5 K C / S giving time of d e p a r t u r e f r o m
B r u s s e l s , destination, estimated time over
Strasburg, Rottweil and Trasadingen. He r e -
quested that the m e s s a g e be relayed to Monaco,
quested and obtained f r o m Zurich the Monaco
QNH. He l a t e r communicated with Frankfurt
on the s a m e frequency, and s t i l l l a t e r , again
by direct message to Zurich ACC, reported
h i s position over Rottweil and Trasadingen.
He then requested to change io telephony on
119.3 M C / S . Having changed to d i r e c t contact
with Zurich control on 119.3 MC/S, he apolo-
gized f o r having been unable to communicate
before because of malfunctioning of the VHF.
Contacts remained normal up to 17.49.10 CMT.
Contact with Milan control
Contact between the a i r c r a f t and Milan
control took place on 3,481.5 and 125.3 KC/S
(the Linate thermoionic r e c o r d e r was out of
o r d e r between 1703 and 1819 GMT because of a
damaged relay. It was, however, possible to
gather f r o m the t r a n s c r i b e d tapes that the r e -
quired position r e p o r t s over the facilities were
estimated in the flight plan.
Contact with Rome control
Contact with Ciampino ACC was initi-
ated according to plan a t 1829 GMT, a t which
time the a i r c r a f t had pasqed over Florence --
o r had s o estimated -- a t 17 500 feet and had
sent Ciampino i t s estimated time over Viterbo
a s 1847 CMT. L a t e r the airc,raft was c l e a r e d
to descend over Viterbo, f i r s t to 11 500 then to
7 500 feet. At 1847, a s noted above, the a i r -
craft should have been over Viterbo and have
s o reported to Ciampino. Not having recelved
this message, a t 1848 C i a m p ~ n ocontrol asked
the a i r c r a f t whether ~t had passed over Viterbo.
Instead of answering this question directly,
the c r e w Inquired whether the Viterbo NDB
 ICAO Circular 5 0 - ~ ~ / 4 5
was on full power. Control replied that an-
other aircraft had overflown the Viterbo NDB
shortly before and had found i t to be operat-
ing properly.
At 1851 GMT the aircraft stated that i t
had passed over Viterbo NDB one minute pre-
viously and requested clearance to descend to
5 500 feet; this was granted. One minute later
it inquired whether the Ciampino ILS were op-
erating and received an affirmative reply. At
1853, 00-SDB called Rome control but com-
munication was suddenly cut off.
The history of the a i r c r a f t supplied by
the Belgian government reveals no element
which might have contributed to malfunction-
ing or deficiencies in i t s operation. Overhauls
of the a i r c r a f t throughout its lifetime were
performed according t o the approved procedure.
The weight of the a i r c r a f t and i t s load distri-
bution a s i t appears on the load sheet were in
accordance with the certificate of airworthi-
ness. The possibility of any sudden malfunc-
tioning shoild be excluded a s there i s no men-
tion of this by the crew in the l a s t message
immediately before the impact.
The weather conditions prevailing along
the route were such a s a r e well known to cause
great disturbance in receiving from radio
beacons on medium frequency; but the crew
had other resources for communication in HF
and VHF, which would have allowed them to
determine their exact position a t all times,
using the corresponding range-finding networks.
It was found that this was not done.
In view of the above-mentioned disturb-
ance in MF communications, the a i r c r a f t cer-
tainly had difficulty in picking up the Viterbo
beacon, a s shown by the fact that while the
estimated time over Viterbo was given a s 1847
CMT, a t 1848 the aircraft was s t i l l asking
whether the Vitetbo beacon was on full power.
The 1851 message, stating that the a i r c r a f t had
passed over the Viterbo beacon one minute
e a r l i e r , when compared with the actual posi-
tion of the a i r c r a f t at the time and with the in-
dication found on i t s radio-compass, leads to
the conclusion that the report was based on a
polar pick-up of the Civitavecchia beacon.
There i s , therefore, good reason to assume
that the a i r c r a f t never was able to pick up the
Viterbo beacon.
It i s evident f r o m the investigation of the
radio equipment that the crew continued the
regular approach procedure, since the units
were s e t on Civitavecchia, Rome City and Rome
6 inserted at the request of the Belgian authorities.
71
Ciampino for the routine communications re-
quired under Ciampino approach procedures.
The inquiry a t 1852 G M T by the a i r c r a f t
a s to whether the ILS was in operation indi-
cates that the crew believed it was already
able to pick up the ILS, whereas this was in
fact precluded by its true position.
It s e e m s strange, in view of the fore-
going, that the crew should not have declared
an a l e r t but should on the contrary have con-
tinued the descent without availing itself of all
the other radio facilities by which it might
have gained exact knowledge of its t r u e posi-
tion.
At the time of the flight the Italian aids
also included two VOR facilities usable on the
route flown -- one in the Milan FIR and one
experimental* in the Rome FIR, -- which
could have given much assistance in pick-ups
and route indications in the Milan and Rome
area.
The airborne VOR facility offered no
clue a s to its setting.
None of the messages f r o m the a i r c r a f t
gave the impression that the crew were in any
doubt a s to their position.
The gradual uncontrolled eastward drift
may be assumed to have started along the
Alpine route, in view of the atmospheric con-
ditions then prevailing, and particularly be-
cause of the jet s t r e a m previously mentioned.
The message "passed Viterbo beacon
one minute ago" sent by the a i r c r a f t a t 1851 i s
certainly an e r r o r - actually, the a i r c r a f t
struck the surface a t 1853 a t a point more than
60 km east of Viterbo on a heading of 163 de-
grees.
Probable Cause
The probable cause of the accident was
that the navigation was conducted without
making use of a l l such radio aids a s would
have permitted checking, and consequently
correcting bhe drift of the a i r c r a f t , whereas
the crew actually remained unaware of the
drift. In fact, instead of making s u r e they
were over the Viterbo beacon, they merely
held that conviction, and therefore the ap-
proach procedure to the Rome terminal a r e a
(which prescribes overflight of the Viterbo
beacon) was erroneously applied.
72 ICAO Circular 5 0 - ~ N / 4 5
The following contributing causes may be
taken into consideration:
- crosswind to the route stronger than
forecast;
- weather conditions particularly unfa-
vourable to radio reception in MF.
Recommendations
Since one of the causes contributing to
the accident was the fact that the crew probably
used only the medium frequency radio aids, and
since reception of the latter may be consider-
ably influenced by weather conditions and night
effect, the Commission makes the following
recommendations :
a) that the European medium frequency
radio beacon network be replaced a t
ICAO Ref: ~ ~ / 4 3 4
/
the earliest opportunity by a network of
radio aids to navigation offering ade-
quate protection a t night and in all
weather conditions prevailing in
Europe ;
b) that, for the Rome terminal a r e a in
particular, work on the following
projects be expedited - relocation of
the Lazio VOR facility f r o m Caste1
-
Decima (410 47 I 05" N 120 28 I 10" E)
to Monte Razzano (420 07i2511N- 120
22'55"E), and installation of a r a d a r
watch;
c) that in a l l c a s e s of difficulty in naviga-
tion, crews be strongly urged to have
recourse to the protection of the HI?
and V H F radio range-finding networks,
when available.
 F";~re 8
General view of crash area.
Gostone dell" ~ q u a s a n ' t i ?ReaLini
,~ Mountains,
74 ICAO Circular 50-AN/45
No. 11
Trans World Airlines. Inc.. Martin 404 a i r c r a f t , crashed on Sandia Mountain,
Circumstances
Having received the following IFR (Instru-
ment Flight Rules) clearance by radio f r o m the
tower a t 0703 hours Mountain Standard Time
"ATC c l e a r s TWA 260 f o r approach a t the Santa
F e Airport via Victor 19 cruise 9 000 feet, report
leaving 9 000,climb northbound on the back course
of the ILS localizerl', the flight departed Albu-
querque, New Mexico, a t 0705 hours, i t s destina-
tion, Baltimore, Maryland, carrying a c r e w of 3
and 13 passengers. The tower requested the
flight to report over the Weiler Intersection*
(formerly the Alameda Intersection), however,
after taking off a t 0705 there were no further
radio contacts with the flight. The a i r c r a f t was
l a s t seen a t an estimated altitude of 3 000 feet
(8 300 feet mean s e a level) in a high speed shallow
climb continuing its heading towards Sandia Ridge,
the upper portion of which was obscured by clouds.
The wreckage was sighted the following morning
a t 9 243 f e e t mean s e a level, just below the c r e s t
of Sandia Mountain, approximately 13 miles north-
east of the Albuquerque Airport and almost direct-
ly on a straight line course of 30 degrees magnetic
f r o m that a i r p o r t (elevation 5 340 feet mean s e a
level) to the Santa F e Airport (elevation 6 344
feet mean sea level), There were no survivors.
Investigation and Evidence
The Albuquerque weather five minutes be-
f o r e the c r a s h was: 4 000 feet scattered, 7 000
feet thin broken clouds; visibility 40 miles; wind
SSE 6; altimeter 29.82; mountains obscured north-
east. Before departure the pilots had bcen brief-
ed on the weather, which was generally clear and
would have permitted visual flight over nearly the
entire route, with only short instrument flight
probable.
Initial investigation was greatly handicapped
and curtailed by deep snow, inclement weather and
dangerously unsure footing on the steep, rocky,
snow-covered slopes. A later expedition reached
the c r a s h site on 3 May and after considerable
difficulty and hazard made an exhaustive study of
the wreckage and found no evidence of f i r e or
* The Wieler Intersection i s the intersection of the 026 radial f r o m the Albuquerque Omni Range
and the back course of the Albuquerque ILS localizer. It is 13 miles north of the center of the
Albuquerque Airport.
structural failure prior to impact, nor of mal-
functioning of either engine o r either propeller.
A study of recovered radio components discloe-
ed that No. 1 VOR Navigation Receiver was
tuned to the frequency of the Albuquerque Omni
Range Station; No. 2 VOR Navigation Receiver
was tuned to the frequency of the Albuquerque
ILS Localizer. However, the flight did not
follow this plan.
The a i r c r a f t was equipped with a Hughes
T e r r a i n Warning Indicator, which simultaneously
flashes a light and sounds an a l a r m when the
a i r c r a f t i s 500 feet, 1000 feet o r 2 000 feet f r o m
any obstruction, a s set. The obstruction may
be anywhere downward f r o m within about 5
degrees of the horizontal in a l l directions -
ahead, a s t e r n , o r to either side.
The wreckage was strewn in a manner
indicating a direction of flight at the moment of
impact of about 320 degrees magnetic while in
a left climbing turn. This means that the aircraft
was turned to its left about 70 degrees f r o m its
original heading and climbed just before the crash,
a s if t o evade a n obstruction.
The pilot must have suddenly realized
that he was ~ r a c t i c a l l va t the vrecivitous wall
of the mountain and acted quickly. We can only
coniecture
- --I- -- a s- t o whether this realization was
spontaneous with the captain, o r the f i r s t officer,
o r induced by a warning f r o m the Hughes Terrain
Warning Indicator of an obstruction ahead, below,
or both: The realization of the mountain ahead
may, of course, have been brought about by
something other than the T e r r a i n Warning Indi-
cator, possibly a glimpse of t e r r a i n close below,
o r ahead, o r both. Obviously an evasive rna-
noeuvre was started.
It is difficult to conceive of the crew at-
tempting to c r o s s a 10 682 foot ridge a t 9 000
feet, especially when the a i r c r a f t was capable
of climbing to a n altitude whi* would more than
clear the ridge. The Martin 404, grossing
40 027 pounds, should , a t maximum continuous
power, climb a t 1 500 feet per minute up to
 - ICAO Circular 50-AN/45
9 000 feet and slightly l e s s than that thereafter.
This rate of climb would have brought the a i r -
craft several thousand feet above the ridge s t a r t -
ing f r o m Albuquerque, only 13 miles away. Even
with much l e s s power the ridge could have been
easily topped. There appears to be no plausible
explanation of why the aircraft was not climbed,
presuming the pilots flew the direct route know-
ingly.
The course flown was off airways and was
neither authorized by the Civil Aeronautics
Administration nor sanctioned by TWA. The
correct and only permissible course i s via Victor
19 airway, which s k i r t s Sandia Mountain to the
west by several miles.
Wind velocity over Sandia Mountain was
indicated to be too light to produce an important
"mountain effectf1such a s s e v e r e turbulence,
downdrafts, and erroneous altitude indications.
Furthermore, such effects when present a r e
manifest over the c r e s t and lee slopes, whereas
this accident occurred on the windward slope.
The captain in command of the flight was
well experienced over the route Albuquerque to
Santa F e . The f i r s t officer was flying it f o r the
I C A O Ref ~ R / 3 9 2
75
f i r s t time that month although he had been over it
twice during the previous month. The weather
was such that visibility along the airway was
good for many miles ahead to the north. The
mountains, although partly obscured by clouds,
were clearly visible f r o m V-19 airway. The
flight took off f r o m Runway 11, circled the a i r -
port to the right, and picked up a northeast head-
ing directly toward Sandia Mountain instead of
pursuing a course along the airway to the west
and north of the mountain. It was contact during
the turn around the a i r p o r t and for approximately
five minutes thereafter before entering the clouds
obscuring the top of the mountain. Even if all
navigational aids and instruments had failed, a l l
the captain had to do was look outside to determine
that he was not following the airway. Therefore,
f r o m a l l available evidence, and the lack of any
evidence to the contrary, the Board can conclude
only that the direct course taken by the flight was
intentional.
Probable Cause
The probable cause of this accident was a
lack of conformity with prescribed en route
procedures and the deviation f r o m airways a t an
altitude too low to clear obstructions ahead.
76 ICAO Circular 50-ANb45
I

Figure 9
T W A , N40416, SANDIA Ill.
Near AJbuquerque, N.M.
FEBRUARY 19, 1955
 ICAO Circular 50-AN/45
De Havilland 104 uDovell, LQ-XWW, crashed on take-off a t Formosa Airport.
T e r r i t o r y of Formosa, Argentina, on 26 February 1955,
Argentine Accident Investigation Report No 465, released 30 August 1955.
Circumstances
The a i r c r a f t on a personnel transfer flight
was taking off a t approximately 15 50 hours f r o m
Formosa Airport with 4 passengers and 3 crew
on board. It was observed to run f o r about 800
metres along the runway, rising only slightly a
few metres before the end of the run; i t then hit
a runway end m a r k e r , the wire fence surround-
ing the aerodrome, and a telephone pole, touch-
ing the ground twice; after demolishing another
wire fence, it came to r e s t against a small hill
and caught fire. Six of the occupants were killed
instantly and the seventh died some months l a t e r
f r o m burns sustained.
Investigation and Evidence
The meteorological conditions a s reported
by the local meteorological station, about 5 k m
f r o m the aerodrome, were a s follows:
sky with 5/8 cumulus with base f r o m
600 to 1 000 metres; wind south a t 8
knots; visibility 20 km; p r e s s u r e a t
station level 997.6 mb; temperature
3 2 O ~ dew
; point 20°c.
The a i r c r a f t had arrived f r o m Cbrdoba
with a stop at Resistencia, landing 25 minutes
before the take-off on which the accident occur-
r i5d.
The ground was carefully inspected and
the t r a c k s left by the a i r c r a f t on the take-off run
were identified. They started 80 m e t r e s f r o m
the runway threshold, where the surface was
muddy. The tracks of the main and front wheels
were clearly visible both on the d r y surface and
in the holes; they disappeared in the central
portion of the runway and reappeared on the
ground near the end marker.
In the f i r s t half of the runway there were
some shallow, hard-bottomed holes which were
crossed by the wheels during take-off; the t r a c k s
left had a maximum depth of 10 c m over 2 me-
t r e s with gradual slopes. The r e s t of the run-
way was hard-surfaced and the only marks upon
it were the normal t r a c k s left by the t i r e treads.
The surface of the runway was covered with
77
g r a s s which, even though not properly mown,
did not interfere with the take-off.
The total weight of the a i r c r a f t was not
recorded before the flight.
The authorized weight empty of the a i r -
craft according to its Certificate of Operating
Limitations was 2 894 kg, or 289 kg over the
normal authorized weight empty; this excess
represented extra radio equipment and spe-
cial facilities, and reduced the disposable
load by the s a m e amount. There remained a
margin of 1 010 kg instead of 1 299 to reach the
maximum authorized take-off weight i. e .
3 859 kg. It was deduced f r o m the tank capa-
city (772 l i t r e s for fuel and 72 l i t r e s for oil)
that the weight of fuel and oil on board was
621 kg, which, added to the weight empty gave
a total of 3 470 kg, thus leaving only 389 kg
f o r crew, passengers, baggage and other
transportable items.
At Cbrdoba, the tanks were replenished
with 430 l i t r e s of aviation fuel, enough f o r
about 3 hours and 15 minutes1 flying time,
thus replacing the arnount of fuel consumed on
the flight f r o m Quilmes.
On departure f r o m ~ d r d o b a ,the esti-
mated weight of the a i r c r a f t was a s follows:
. ..... . .... 2 849 kg
Weight empty.. ,
...... .... . 556
.. .... ..... ... 140
Fuel (772 l i t r e s )
Oil (72 l i t r e s ) , 65
Baggage and miscellaneous.
Crew and passengers (6). .... 4 80
Maximum licensed weight.. .. 3 8 59 kg
Excess 2 3 1 kg
The flight f r o m CSrdoba to Resistencia
required 2 hours and 45 minutes with a con-
sumption of about 260 kg; a t Resistencia 230
l i t r e s of fuel and 9 l i t r e s of oil, totalling 173
kg were taken on board; 80 kg were consumed
on the t r i p to Formosa and an additional pas-
senger was taken on for the return flight,
 78 ICAO Circular 5 0 - A ~ / 4 5
making a total of seven persons on board. In
summary, the a i r c r a f t took off f r o m Formosa
with 4 003 kg, 87 kg l e s s than f r o m CSrdoba,
but still 144 over the maximum licensed weight
of 3 859 kg.
Inspection of the propellers at the site
showed that the blades were set on high pitch,
except one of those of the left propeller which
was facing forward, turned about 100 degrees
f r o m the high-pitch position. The other two
remained in position, both firmly meshed with
the driving gear, although one of them was bent
backwards f r o m contact with the ground. The
blade found in the inverted position turned free-
ly, overcoming only the normal friction of the
packing of the mounting on the hub; the impact
caused failure of the screws and locking pins
holding the control gear segment. The right
propeller blades were also bent back by impact,
and one of these had broken f r e e of the gear seg-
ment f o r the same reason.
The propeller controls, having been com-
pletely destroyed by fire, could not be checked,
and there remains a doubt whether, in the e m e r -
gency shutting of the throttles, the propeller
controls were moved at the same time to the
high-pitch position, o r whether they slipped
during the take-off run and the fact was only
noticed a t a late stage. The latter would ex-
plain the Impression of acceleration o r increase
in r p m gained by witnesses to the departure.
As the right engine had been destfoyed in
the f i r e and all its working parts and attachments
were melted together, detailed inspection of
components was impossible.
The left engine only suffered slight fire
damage to its r e a r attachments, the remaining
ones and the engine itself being only heated o r
smoke-blackened. It was possible to check the
distributors, which showed no sign of the inter-
nal burns common in such cases; neither did the
contact b r e a k e r s display any abnormal signs.
The spark plugs installed in this engine
were of various makes and types, some of them
with long, thick, bent electrodes, with excessive
wear on the side electrode.
The technical report on the dismantled
engine revealed the presence of marks of incom-
plete detonation on the piston crowns and one ex-
haust valve seat was burnt and the other pitted.
The presence of spark plugs inappropriate
to this type of engine, in which the ambient tem-
perature and that at the cylinder heads a r e un-
doubtedly high, as i s also the intake p r e s s u r e re-
quired for take-off, caused premature ignition,
ICAO Ref: AIG/ACC/REP/GEN/NO. 7
(Arg, Bulletln No. 4 , p. 31)
r,
followed by the detonation revealed by the ins-
pection, in the dismantled engine o r in both,
thus inevitably producing loss of power and
i r r e g u l a r operation.
It was not possible to determine the
circumstances in which the propeller blades
were switched to high pitch; the very magnitude
of such an e r r o r s e e m s to rule out the theory
that they were in this position a t take-off; even
if this irregularity had escaped the pilot's at-
tention, it may be assumed that it would have
been noticed by the flight mechanic, who usu-
ally stands between and slightly behind the
seats of the pilots during take-off, o r by the
co-pilot, who was in the right-hand seat; it is
considered possible, however, that the pro-
peller pitch controls could have slipped to the
high-pitch position during the take-off run,
without this being observed in time.
Weather conditions a t the scene of the
accident were such that the a i r density was 8%
below normal and the ambient temperature re-
duced driving power by about 3 % . Had the
a i r c r a f t ' s engines been operating normally,
the meteorological factor would have reduced
i t s forward and vertical speeds, although a run
of 800 metres would have given i t sufficient
speed to climb a t a much f a s t e r rate than i t s
actual 0.50 m/sec, which was inadequate to
clear the f i r s t obstruction, 1 m e t r e high.
Probable Cause
The accident was due to the inability of
the a i r c r a f t to reach i t s take-off speed after a
run of 800 m e t r e s on the runway, because of:
1) Insufficient driving power f o r opera-
tion, resulting from:
a) Reduction in power in one o r both
engines f r o m premature ignition
and detonation, originating in the
use of spark plugs inappropriate
to the engine type.
b) Probable reduction in the r p m rate
of the engines during the t ake-off
run; following unnoticed slipping of
the propeller controls
2) Overloading of the aircraft in rela-
tion to maximum authorized take-off weight.
3) The circumstances in which the oper-
ation was c a r r i e d out indicate that the weather
conditions in relation to the characteristics of
the runway were a contributing cause of the ac-
c~dent.
 ICAO Circular 3 0 - ~ ~ / 4 5 79

-
No. 13

Circumstances of 600 feet. On a r r i v a l over the station the

heading i s maintained and the descent continued
The a i r c r a f t departed Jan Smuts Airport until the a i r c r a f t makes visual contact with the
a t 1115 hours local time on a scheduled flight to ground o r reaches a height of 500 feet, the
Belvedere Airport, Salisbury, under VFR condi- general critical height laid down for the a i r -
tions carrying 23 passengers and a crew of 5. port. (In the case of Central African Airways
At 1427 hours while approaching Runway 09/27 a critical height of 400 feet has been approved.)
f r o m the east on final approach during a thun- On making visual contact with the ground an
d e r s t o r m the undercarriage struck the ground a aircraft i s travelling approximately a t right
short distance to the north and east of the thres- angles to the runway. The a i r c r a f t must then
hold of Runway 27p causing the starboard t i r e manoeuvre into a position to enable a landing
to burst, the starboard leg of the undercarriage to be made. The usual procedure i s to turn to
to break and the starboard propeller engine to starboard and t o land on Runway 09.
be severely damaged. The pilot endeavoured to
undertake overshoot procedure but a s the s t a r - There i s no instrument at the a i r p o r t ca-
board engine and propeller could not deliver pable of measuring the height of low cloud.
power and the a i r c r a f t was a t a speed below the This i s done by an officer on duty who makes an
minimum required for effective control he was estimate f r o m a llpointllnear the airport build-
obliged to make a c r a s h landing. No one was ings f r o m which there i s good visibility to the
injured but the a i r c r a f t was extensively damage'd. south and to the west, enabling the o b s e r v e r to
estimate adequately the height of low cloud in
Investigation and Evidence those directions, more particularly in the a r e a
in which an aircraft intending to come on Run-
The main runway (09/27) i s 2 600 yards way 09 would be. There i s v e r y poor visibility
long of which 1 000 yards a t the eastern end i s to the east and to the north and f r o m the "pointl1
grassed, the remainder of the runway being it i s impossible to make any estimate of the
hardened and s o available for use in a l l weather height of low cloud in the region in which an a i r -
conditions. At either end of the hardened run- craft intending to come in on Runway 27 would
way there i s a hardened taxiway. The altitude be or to make the best possible estimate of hori-
of the airport i s 4 780 feet above mean s e a level zontal visibility. The MET Office informs the
and the distance required for a fully loaded a i r traffic control officer in hourly reports of
Viking to land a t that altitude in standard atmos- conditions and these a r e passed on to approach-
pheric conditions i s approximately 1 350 yards. ing aircraft. No log of messages i s kept in the
control tower a s this i s considered impractic-
The two radio aids to navigation at the able because messages a r e passed to and f r o m
airport a r e a non-directional beacon and a V H F the tower by radio-telephony.
direction finder. The former i s situated a short
distance to the north of the airport buildings and The a i r c r a f t flew f o r the greater part of
the latter to the south of the main runway. Ei- the journey a t 11 000 feet above cloud. Amend-
ther may be used for descending through cloud. ments to the route weather forecast indicated
The procedure in each instance i s somewhat the that active and extensive thunder s t o r m develop-
same and i s , in outline, that in IFR conditions ment was expected at Salisbury. Cloud was
an aircraft approaches a t a height of 1 500 feet given as' 1/8 cumulonimbus a t 1 000 to 2 000 feet,
over the station (i.e. 6 300 feet above mean sea 1/8 strato-cumulus 1 000 to 2 000 feet, 2/8 cu-
level) and on a heading of 020°. After passing mulus at 1 000 to 2 000 feet, 7/8 altostratus a-
over it, the a i r c r j f t continues on this heading bove 8 000 feet.
for two minutes. It then effects a procedure
turn on to a reciprocal heading of 200°, when a 1404 .. the a i r c r a f t announced i t was ap-
descent i s commenced down to a minimum height proaching f r o m the southwest a t
9 000 feet IFR and was provided
9 The eastern end of the hardened surface of Run- with the prevailing QNH and QFE...
way 09/27 i s r e f e r r e d to a s the threshold of Run-
way 27.
80 ICAO Circular 5 0 - ~ ~ / 4 5
52
0

1412 . . flying a t 6 300 feet and informed
that rain was moving in f r o m the
northeast ...
1415 .. given clearance to approach right-
handed on to Runway 09 ...
1418 .. crossing the Hunyani River a t 600
ing on right-hand base leg ...
feet flying VFR and indicated join-
1420 .. told that approach to 09 was ob-
acured and c l e a r to join circuit
f o r Runway 27. At approximately
the same time the aircraft report-
ed 09 in sight and requested per-
mission to land on that runway or
indicated it intended to land there.
The control tower had advised the a i r c r a f t there were two crucial limiting factors. The
Of the storm moving into the aerodrome f r o m
the northeast but no mention had been made of a
covering the Warren Hills. The hills a r e grassed portion of Runway 27. The effects of
200 feet high and some two miles
west of the airport, roughly a t right angles to
Runway09/27. A gap in these hills i s in line
with this runway. In conditions of good visibil-
lty aircraft coming in on 09 fly over the hills
and Pass through this gap. On this approach
the aircraft was being flown by the f i r s t officer
the left-hand seat, the captain being in
the right-hand seat. The captain and the f i r s t
Officer were aware of the s t o r m and, therefore,
not permit the aircraft to be flown further
west for the usual final approach. Therefore,
the aircraft turned inside the hills and tried to
come in on 09. After the turn f r o m the base leg figure would appear to be on the optimistic
it apparent to the f i r s t officer and the
captalt~that the a i r c r a f t would not be able to
land on the runway without having to make use
Of the additional thousand yards of g r a s s a t the
eastern end of the runway. The captain decided
On Overshoot procedure and took over f r o m the
first officer when the aircraft was 50 f e e t above
the runway. The f i r s t officer then took over
again and was instructed to alter course by
20° north of the line of the runway - due
to the kopje (hill) to the east of the runway
obscured by another storm. The a i r c r a f t
''Imbed to 1 200 feet over the town a t which
point the captain and f i r s t officer changed places, not know that the weather would improve. The
the moving to the left-hand seat. A pro- criticisms of the plan a r e that it involved a
cedure turn over the town was completed which
brought the a i r c r a f t back on a course approxi-
m a t e l ~reciprocal to that on which it had just
left the a r e a of the runway. At about thls time
there Was a s t o r m to the north and northeast of
the buildings, another s t o r m in the k0pje the turn and that there would be difficulty in
area Probably extending ever, at this stage over
part Of the g r a s s e d portion to the east of the
threshold of Runway 27, and clear conditions
over the t o m . The a i r c r a f t reported coming
lion fi nal to Runway 27", the message was ac-
knowledged by control who did not communi-
cate further with the aircraft.
The captain planned to approach the run-
way at an angle. This plan necessitated a
turn to starboard through some 20° when a t a
height of about 20 feet above the runway, in
o r d e r to align the a i r c r a f t with the runway.
The captain estimated that he would then have
touched down 200 to 300 yards f r o m the thres-
hold of the runway leaving 1 300 to 1400 ~ a r d s
in which to stop. The plan was a bold one and
somewhat difficult to execute because i t gave
him little o r no margin for e r r o r . The cap-
tain was quite confident that he could have
c a r r i e d out this plan, i f no circumstances had
supervened to interfere. In making this ~ l a n
f i r s t was the presence of the s t o r m in the a r e a
of the kopje and the a r e a covering part of the
this factor were, f i r s t , that it was impossible
to make a straight approach to Runway 27
without losing sight of the runway and, second-
ly, that it was impossible to make the turn to
align with the runway to the e a s t of the thres-
hold. The other limiting factor was the length
of Runway 27. It would have been necessary
for the aircraft to touch down within about
300 yards of the threshold in order that it
should be able to stop before the western end.
In this regard the captain stated that he had
previously pulled up a Viking a i r c r a f t in sim-
ilar conditions in under 1 000 yards. This
side even with exceptional application of brakes,
but it must be borne in mind that had the cap-
tain not been able to touch down at a point
giving him sufficient distance in which to stop,
he should have had no difficulty in taking over-
shoot action. His p r i m a r y duty was t~ land
his a i r c r a f t safety a t Belvedere; his alternative
to making an attempt to land was to go to
Lusaka, the recognised alternate a i r p o r t to
Belvedere. A further alternative was to wait
in the vicinity of Belvedere in the hope that
the weather would improve, but he could not
have done so for an unlimited time and he could
turn a t the unusually low height of some 20
feet above the ground, that the aircraft would
be travelling faster than usual a t that height
because of the additional speed necessary to
compensate f o r the extra loading imposed by
ensuring alignment of the a i r c r a f t with the
runway on completion of Ihe turn.
 ICAO Circular
Notwithstanding the existence of the
limiting f a c t o r s already mentioned, and bear-
ing in mind the fact that there would have
been ample opportunity to take overshoot pro-
cedure if the a i r c r a f t had not been able to
touch down at about the planned point, the
Board finds that the captain acted reasonably
in embarkihg on his plan.
The question remains whether his con-
duct was a t fault in the course of carrying out
the plan.
The f i r s t impact took place some 10 feet
to the east of the taxiway that runs a t right
angles to the threshold of Runway 27, and about
100 feet to the north of the centre line of the
Runway. That the impact was severe i s un-
douhted, f o r , in addition to the damage caused
to the a i r c r a f t , some of the marks made by
the blades of the starboard propeller in the
hardened surface of the taxiway were 2 inches
in depth and the distance over which the marks
extended ..vas about 140 feet. It was undoubtedly
the starboard wheel of the aircraft that f i r s t
struck the ground. It i s c l e a r f r o m the mark
made by the starboard wheel, the m a r k made .
by the port wheel, and a l s o the line of marks
made by the blades of the starboard propeller
that the line i n which the aircraft was travelling
was the line planned by the captain to bring the
a i r c r a f t over the centre of the runway at about
the anticipated point. The fault in the position
of the a i r c r a f t was its altitude and it i s neces-
s a r y to c7nsider how this l o s s of altitude was
caused.
At o r about the time of the f i r s t impact
there was a great deal of rain about. All the
witnesses who spoke of this time said that
there was heavy rain but could not say whether
or not there was any rain at o r about the thres-
hold of Runway 27. The evidence of the cap-
tain i s that, a s he made his approach in accord-
ance with his plan, he could, when the a i r c r a f t
was at an altitude of about 300 feet, s e e the
whole of Runway 27. He was a t this time in
rain but not particularly heavy rain and with
the aid of the windscreen wipers, which were
working a t the maximum pace, he was able to
see clearly. At this stage there was nothing
to suggest to him that he would not be able to
c a r r y out his plan. He said that, as he contin-
ued his approach, there was a sudden downpour
of rain which obscured his view completely in
spite of the fact that the windscreen wipers
were working a t maximum r a t e . At about the
same time, he felt a surge of the a i r c r a f t down-
wards which he sought to c o r r e c t , and a t the
same moment started to take overshoot proce-
dure. As he was in the course of opening the
throttles the starboard wheel struck the ground.
The captain said that the surge was not sudden
and would be unlikely to be noticed by anyone
other than the pilot. There i s thus no evidence
to support him on this point. There is no di-
r e c t evidence t o support his statement that
there was a sudden fall of rain which obscured
his view. The f i r s t officer was a t the time
engaged in setting additional flap that had been
called for and was watching the flap indicator.
The radio officer was facing forward but be-
cause of his position was unable to s e e what
the visibility was through that part of the wind-
s c r e e n covered by the wipers. However, he
supports the captain's statement. that imme-
diately before impact the latter was in the
course of opening the throttles because he saw
this happening. The f i r s t officer also supports
the captain's evidence because, when he looked
up after the impact, he was unable to s e e
through the windscreen at all. Observers on
the ground, who were a t o r in the a i r p o r t build-
ings, were able to s e e the a i r c r a f t throughout
this period, but the evidence showed that very
heavy rain completely obscures visibility
through the windscreen of a Viking, in spite of
the use of windscreen wipers.
The Board accepts it a s established that
v e r y shortly before the f i r s t impact there was
a sudden unexpected fall of rain which com-
pletely obliterated any view that the captain
had and also that the c l e a r view panel was i n
the circumstances of no assistance to him be-
cause of the angle of the a i r c r a f t in relation
to the runway.
As regards the suggestion by the cap-
tain that the surge downwards was caused a s
a result of a down current produced by the
sudden fall of heavy rain, the Board finds that
this i s a possible explanation for it, but con-
s i d e r s that there i s another possible explana-
tion for the l o s s of altitude. It would s e e m
that a sudden l o s s of vision might well result
in a momentary disorientation, of which the
pilot would be temporarily oblivious, causing
the a i r c r a f t to lose height.
The Board can go no further than to s a y
that the l o s s of height was probably occasioned
either by the downdraft suggested by the cap-
tain o r by the momentary disorientation al-
ready r e f e r r e d to, o r by a combination of both.
I b i s apparent that the unexpected occurrence
was sudden and that a s i t occurred a t a critical
height the captain had insufficient time to take
effective corrective action. It i s c l e a r , more-
over, that a l l this occurred in a very short
space of time,
 82 ICAO Circul a r 5 0 - ~ N / 4 5
Nearly every witness who saw the a i r c r a f t
approaching the point a t which i t f i r s t struck the
ground considered that it did not appear to be
coming in as Vikings usually did; some thought
that the angle of descent was steeper, and some
thought that it was travelling f a s t e r than usual.
There i s no doubt that the a i r c r a f t was in an un-
usual position because at the #timeit struck the
ground it was flying into the ground and was not
"flaring outtt a s i t would normally be doing. It
was also in the position that i t s starboard wing
was lower than its port wing. It was undoubtedly
travelling f a s t e r than usual. This was by design
because the captain considered that it was ad-
visable to do so having regard to the fact that he
was in the course of turning. The explanation
for the evidence of these witnesses would appear
to be that the approach was f r o m an unusual
angle, that i t was made on a turn and that there
was no ttflare-outll.
The fact that the starboard engine was
damaged was unknown to the captain but he very
soon discovered, having opened the throttles and
started to climb, that the starboard engine was
useless ; he therefore took the action necessary
to feather the propeller and to close the throttle.
It i s not established whether the propeller actu-
ally feathered, but it s e e m s unlikely that this
occurred because of the damage that had been sus-
tained. At this time the speed had dropped to
about 85 knots which i s l e s s than the minimum
speed required for effective control of the a i r -
craft. The drag f r o m the starboard propeller
and the power being delivered by the port engine
caused the aircraft to yaw uncontrollably to s t a r -
board notwithstanding the full application of rud-
der and aileron to oppose the turn. In these c i r -
cumstances the captain decided to endeavour to
c r a s h land the aircraft. His impression was
that he selected the undercarriage up for this
purpose. After the a i r c r a f t came to r e s t the
lever was, however, in the down position. He i s
unable to explain this beyond saying that he i s
certain that he tried to r a i s e the undercarriage
but that in the heat of the moment he may not
have realised that he had not done so. It i s doubt-
ful whether his airspeed a t the time exceeded 85
knots, in which case a safety device fitted to the
aircraft would not permit the undercarriage to
be raised unless a t r i p switch were operated.
The captain i s certain that he did not operate
the t r i p switch because that involved the use of
two hands, the right hand on the undercarriage
operating lever and the left hand on the t r i p
switch. He i s quite clear that he did not use both
hands for this purpose. In the result he c r a s h
landed the aircraft taking all appropriate action
to do so. The petrol and oil cut-off levers were
thrown out on touching the ground and a s the a i r -
craft came to r e s t the fixed f i r e extinguishers
fitted close to the engines were s e t off.
Probable Cause
The accident was caused not by mechan-
ical defect of the a i r c r a f t nor by the conduct
of the pilot but by a combination of unusual
and unexpected circumstances . Had the sud-
den downpour of rain not taken place a t the
critical moment, it i s almost certain that no
accident would have occurred.
Observations and Recommendations
There i s little margin, when the g r a s s
portion of Runway 09/27 i s unserviceable for
aircraft landing, especially in a westerly di-
rection, since the runway slopes slightly
downwards f r o m east to west and there i s
little over-run a t the western end.
The Board recommends that the hard-
ened runway be extended towards the east in
order to provide a g r e a t e r length of all weath-
e r surface if this airport i s to be used indefi-
nitely for Viking aircraft. The qualification
is made because the Board i s aware of pro-
posals to use a different airport at o r n e a r
Salisbury in substitution f o r Belvedere a s the
principal airport for the use of the a i r c r a f t of
airline operators. But this point was not dealt
with in the evidence and therefore no accurate
details of the position were made known. In
these circumstances, the expense of extending
the hardened runway may not be justified. The
recommendation must therefore be considered
in the light of these factors.
Another approach to this problem would
be to limit the operational weights of Viking
aircraft when the grassed portion of the run-
way i s unserviceable and high atmospheric
temperatures prevail.
Whatever may be the ultimate decision
in this connection, the question of the service-
ability o r otherwise of the grassed portion of
the runway during wet weather remains. At
present, there i s no satisfactory means of
determining its serviceability and no proce-
dure i s laid down a s to when and how this i s
to be done. If it i s deemed unserviceable, a
radio message to this effect i s sent out to a i r -
craft but no visual signs a r e ~ p l a c e don the
ground to indicate th; unserviceable parts.
It i s , therefore, recommended that a proper
procedure be laid down for the determination
of the condition of the grassed p a r t of the run-
way and that, if the whole o r p a r t be deemed
 ICAO Circular 50-
unserviceable, appropriate visual signals b e
placed on the ground to show this, in addition
to the transmission of the information by radio,
Evidence indicated that not all the f i r e
fighting vehicles arrived at the scene of the
crashed a i r c r a f t , partly due to the unsuitability
of the type of some of the vehicles. The evi-
dence also indicated that the replacement of all
the present vehicles with vehicles of appropri-
ate type had already been considered arid that
steps in this direction have already been taken.
The Board views with favour these proposals
and recommends that this policy be c a r r i e d out
in due course.
There does not appear to be v e r y c l e a r
definition of the respective functions of Meteor-
ological Officers and Air Traffic Control Offi-
c e r s in respect of passing meteorological infor-
mation to a i r c r a f t approaching Belvedere when
variable weather conditions exist. The Mete-
orological Officers a r e mostly on duty inside a
building and consequently cannot be expected to
be aware of the details of changes in variable
weather conditions; the Air Traffic Control
Officer, on the other hand, i s favourably situ-
ated to observe such changes. The Air Traffic
Control Officer on duty did not inform the ap-
proaching Viking of the existence of the s t o r m
over the Warren Hills. This failure to do s o
probably had no bearing on the events that took
place because the s t o r m was seen by both the
captain and the f i r s t officer. Emphasis must
be on the passing of the maximum information
about weather to a i r c r a f t to enable a planned
approach to be made with the greatest possible
safety. With this end in view, the Board recom-
mends that the matter of the respective functions
of Meteorological Officers and Air traffic Control
Officers be investigated and their respective func-
tions be clearly defined.
As has already been indicated the position
f r o m which estimates of the base cloud a r e made
i s one f r o m which i t i s impossible to make any
proper estimate in the region lying to the east of
Runway 27, which i s the critical a r e a for aircraft
seeking to come in on that runway. Furthermore,
estimates of horizontal visibility for .use by a i r -
craft s o coming in ought to be made f r o m a point
n e a r e r the threshold of that runway in order that
the observer should have a view comparable with
that of the pilot of an aircraft. Accordingly, it
i s recommended that these observations should
be made f r o m a point which will give the observer
an opportunity to conform to these criteria.
The evidence indicated that although,
strictly speaking, a control zone should have
been imposed in the weather conditions which pre-
vailed a s the a i r c r a f t in question approached
the airport, no control zone was imposed by
the Air Traffic Control Officer. The absence
of the imposition of such a zone had no bearing
upon the events that took place because the
critical difficulties met by the pilot of the a i r -
craft occurred when the a i r c r a f t was l e s s than
400 feet above the aerodrome. Moreover, the
Viking in question was the only a i r c r a f t ap-
proaching Belvedere a t the time. Variable
weather conditions such a s these undoubtedly
present great difficulties to those concerned
with the control of approaching aircraft.
The question a r i s e s whether some pro-
vision of a radio aid should not be made which
will enable an a i r c r a f t approaching in IFR
conditions, including "partial IFRtl, to deter-
mine accurately its position in relation to the
airport before commencing a descent below the
prescribed minimum safety height for the
route flown. In the case of this Viking the
descent below the route minimum safety height
was made on an estimated position. During
this descent the a i r c r a f t was 3 miles off track
when it made a visual fix at Beatrice though,
in fact, no danger existed. It i s , however, by
no means difficult to imagine circumstances in
which an a i r c r a f t approaching would be un-
certain whether it was safe to descend; further,
it i s not difficult to imagine the danger that
might be associated with a descent under those
circumstances. This aspect of the matter i s
put into high relief when i t i s observed that the
minimum safe flight altitude for the route
~ a l i s b u r ~ / ~ o h a n n e s b u r ~ / ~ a l i has
sburbeen
~
laid down by Central African Airways in ac-
cordance with section 72(8) (a) (ii) of the Air
Navigation Regulations, 1954, a s 8 000 feet.
The procedure for letting down, using naviga-
tion facilities, provides for the let-down to
s t a r t a t "pattern heightt1of 6 300 feet, that i s
to say, 1 500 feet above the aerodrome. There
i s thus no clear definition of the point a t which
it i s safe for an a i r c r a f t to descend f r o m 8 000
feet to 6 300 feet, except perhaps that an a i r -
craft could ascertain i t s position before descend-
ing below 8 000 feet by flying at that height
over the beacon. This i s apparently not a s a
rule done and, in any event, it would appear
to be more desirable that an a i r c r a f t should be
able to descepd to pattern height while approach-
ing the aerodrome. Such a situation would be
rectified by the provision of a radio aid to nav-
igation situated in such a way a s to enable an
aircraft to determine i t s position accurately in
relation to the airport a s it approached. This
having been done, the a i r c r a f t could descend to
84 ICAO Circular 5 0 - ~ ~ / 4 5
pattern height without risk. The Board recom-
mends that this matter be investigated, bearing
in mind that any aid provided could be design-
ed to be of use in connection with any airport
that might in future take the place of Belvedere.
The Board has considered the question
whether it would be desirable to provide a radio
beacon situated to the west of the runway and
aligned with i t in order that a i r c r a f t coming in
on a let-down procedure would be aligned with
the runway during the final stages of the let-
down and not at approximately right angles to it.
The obvious disadvantages of such a procedure
a r e the presence of the Warren Hills and the
fact that a i r c r a f t would have to come through
the gap in bad weather conditions. The provi-
sion of such a beacon would involve a complete
revision of the existing let-down procedure and
a great deal of investigation. If in the fairly
near future a new airport i s to be substituted
for Belvedere it i s obvious that such a change
is not warranted. On the other hand, the Board
recommends that the matter be investigated if
Belvedere i s to be used indefinitely.
The evidence showed that the New Salis-
bury Airport which lies within the a r e a of the
control zone of Belvedere has a control tower
which i s not always manned. It would appear
that, while there i s some co-ordination between
the movement of a i r c r a f t between the two a i r -
ports, this co-ordination i s somewhat inade-
quate. It i s therefore recommended that this
matter should be investigated.
The a i r traffic control officer on duty at
the time of this accident had had considerable
experience in his duties and was properly quali-
fied . It emerged, however, that he had been
examined to ascertain his capabilities upon a
syllabus and by examinations s e t by the Airport
Manager, Belvedere. While i t i s not suggested
that the syllabus and the examination were not
completely adequate, it would appear that there
should be some uniformity of practice in the
matter throughout the Federation, and it i s r e c -
ommended that this should be investigated.
The absence of a complete record of R/T
messages passing between Control Tower and
Aircraft caused some difficulty in the investiga-
tion of the events that led up to the accident now
in question because recollections varied a s to
what was said and the sequence in which mes-
sages passed. While it does not appear to be
necessary to have a recording device merely
because another accident might take place, it i s
recommended that the question should be inves-
tigated whether o r not the p r o v ~ s i o nof such a
device would be d e s ~ r a b l e .
-
MEMORANDUM BY THE MINISTER OF
TRANSPORT AND COMMUNICATIONS
FEDERATION OF
RHODESIA AND NYASALAND
The following a r e the views of the Gov-
ernment with regard to the recommendations
that have been made in this report.
The Airfield
The 1 600 yards of hardened runway a t
Belvedere a r e adequate f o r Viking a i r c r a f t ,
save, perhaps, in the event of take-off in the
westerly direction when the 1 000 yards of grass
runway a t the eastern end of the hardened s u r -
face a r e unserviceable and, a t the same time,
weather conditons a r e unfavourable f o r the
take-off. Such a combination of conditions i s
r a r e , but when it does occur, the take-off will
be deferred o r the take-off weight will be re-
stricted. While landing f r o m east to west, the
position i s that even if the grassed part of the
runway i s unusable, it i s f r e e of obstructions
and, therefore, a i r c r a f t can land close to the
end of the tarmac runway, thus ensuring that
the landing run i s completed well within the
1 600 yards of tarmac available.
In view of the low incidence of take-offs
and landings in the westerly direction at Bel-
vedere, the safety measures applied, and the
expected move to the new Salisbury Airport in
the near future, the extension of the existing
Belvedere hardened runway i s not justified. It
will be seen that the Board's recommendation
in this respect i s , in fact, qualified.
No practical method of determining with
precision the serviceability of the g r a s s runway
is known. Consequently, the practice has been
adopted of declaring the entire a r e a unservice-
able whenever doubt exists. There i s , there-
f o r e , no need to display visual signs to distin-
guish between the serviceable and unserviceable
portions.
Meteorological Department
The respective functions of meteorologi-
cal officers and a i r traffic control officers a r e
defined under international rules established by
the World Meteorological Organization and the
International Civil Aviation Organization, and
these a r e inaplemented in the Federation. Any
need for am-,lificatlon of existing instructions
 ICAO Circular 5 0 - ~ ~ / 4 5 85

will be examined. In addition, arrangements Air Traffic Control

have been made whereby a meteorological offi- At the present time, the new Salisbury
c e r will in future be present in all aerodrome Airport serves purely as a military air station,
control towers when a i r c r a f t a r e a ~ ~ r o a c h i n g and whilst i t is available for use by civil aircraft
in marginal weather conditions. in emergencies, normally, only the R.'R.A.F.
man the-control Tower while their flying opera-
Radio Aids t o Navigation tions a r e in progress. When this military flying
i s taking place, proper co-ordination i s effected
A radio beacon has been in operation a t with the Control Tower and Flight Information
Norton since January of this year, one purpose Centre at Belvedere by direct land line commu-
of which i s to enable aircraft, before commenc- nication. Arrangements a l s o exist whereby dur-
ing a descent, to determine their position accu- ing non-flying periods, duty staff a t the Military
rately whenever this cannot be done by visual Air Station will render assistance in the event of
reference to the ground. However, a descent to an emergency landing by a civil aircraft.
6 300 feet f r o m an estimated position i s perfect-
ly safe at Salisbury where the obstruction level Belvedere i s the training centre for a i r
i s well below this height. traffic control officers in the Federation, and
the training syllabus and examinations s e t bv
the ~ i r ~ oManager
r f there a r e based on in&-
The life of Belvedere i s limited. The national requirements in respect of a i r traffic
present let-down s y s t e m has been established control procedure. The syllabus i s , in fact,
a s perfectly safe and adequate provided aircraft compiled in conjunction with other members of
do not attempt to approach in conditions below the Civil Aviation Department, and i s approved
the approved weather minima of 2 000 yards by the Director. Training i s uniform throughout
horizontal visibility, and a 400 foot cloud base. the Federation.
In view of the surrounds of this a i r p o r t it would Tape recording equipment for radio tele-
be extremely costly, if at a l l possible, to pro- * phone messages will be installed a t the new
vide a let-down s y s t e m which would be an im- Salisbury Airport, but i t i s not considered justi-
provement on the present one. Here, too, the fiable a t the other a i r p o r t s in the Federation a t
Board's recommendation i s qualified. the present time.

ICAO Ref: ~ ~ / 3 8 8
86 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
/

No. 14

American Airlines, Inc. Convair 240 a i r c r a f t , c r a s h e d n e a r

Springfield, Missouri, on 20 M a r c h 1955. Civil Aeronautics
B o a r d (USA) Accident Investigation Report No. SA-305,
F i l e No. 1-0038, r e l e a s e d 22 September 1955

Circumstances c a m e to r e s t in an upright position on a head-

The flight took off f r o m Newark, New
J e r s e y , a t 1245 h o u r s C e n t r a l Standard T i m e
en route to Tulsa, Oklahoma, with s e v e r a l
intermediate stops including Chicago, Illinois,
and St. Louis and Springfield, Missouri, c a r r y -
ing 32 p a s s e n g e r s and 3 crew. Due to low
ceiling and visibility f o r e c a s t f o r Springfield
the flight was delayed over an hour a t St.Louis
i n o r d e r that another a l t e r n a t e a i r p o r t (Gage,
Oklahoma) could be selected and additional
f u e l might be taken on i n c a s e Springfield had
to be overflown. The I F R (Instrument Flight
Rules) c l e a r a n c e i s s u e d by ARTC ( ~ i Route r s e p a r a t e d and destroyed by the i m p a c t and an
T r a f f i c c o n t r o l ) specified in p a r t that t h e
flight was c l e a r e d t o the Springfield VOR
(Visual Omni ~ a n g e Station ) v i a Victor Airway
14 and was to maintain 4 000 f e e t m e a n s e a
level. At 2218 h o u r s the a i r c r a f t contacted
Springfield Approach Control and a f t e r receiv-
ing the weather r e p o r t advised that i t s esti-
m a t e d time of a r r i v a l a t Springfield was 2233
h o u r s . The approach controller t r a n s m i t t e d
the 2208 weather observation to t h e flight and
i t was c l e a r e d for a s t a n d a r d range approach
and instructed to r e p o r t when o v e r the range
station and a l s o when starting the procedure
turn. The flight informed the controller i t
would make a circling approach t o Runway 31
.
and a t 2234 r e p o r t e d l l . . o v e r the Omni a t 34,
proceeding to the field." Approximately two
minutes l a t e r , while proceeding directly f r o m
the VOR station toward the a i r p o r t , not execut-
ing the CAA approved VOR i n s t r u m e n t approach
procedure, the a i r c r a f t descended and s t r u c k
the ground 1-1/4 m i l e s north-northwest of the
Municipal Airport. Eleven of the p a s s e n g e r s
and 2 c r e w m e m b e r s w e r e fatally injured.
ing of 240 degrees. It was determined that the
landing g e a r w a s fully r e t r a c t e d and t h e flaps
w e r e extended about 19 d e g r e e s .
Impact f o r c e s w e r e s e v e r e and high
v e r t i c a l and f o r e and a f t f o r c e s w e r e developed
during the initial ground contact. T h e s e f o r c e s
b r o k e the nose section f r o m the fuselage and
c r u s h e d the lower s t r u c t u r e upward t o the
floor support beams. V e r t i c a l c o m p r e s s i o n
buckling was induced i n a r e a s which did not
contact the ground and deflected the s i d e s of
t h e fuselage outward. The right wing was
explosion which o c c u r r e d in t h e fuel tank a r e a .
The left wing was t o r n off and c a m e t o r e s t
relatively intact i n an inverted position s e v e r a l
y a r d s ahead of the m a i n wreckage. The pas-
s e n g e r s e a t s , with the exception of the l a s t row,
w e r e t o r n f r e e and thrown forward. Examin-
ation of this wreckage, although s e v e r e l y dam-
aged, disclosed no evidence of fatigue cracking,
s t r u c t u r a l f a i l u r e , o r malfunctioning controls
p r i o r to i m p a c t ,
Both engines w e r e t o r n out and broken
into s e v e r a l sections by impact. Examination
of their combustion c h a m b e r s , o i l pumps, oil
s c r e e n s , front and r e a r a c c e s s o r y d r i v e s and
bushings, and i n t e r i o r s of the power sections
failed to d i s c l o s e evidence of malfunction o r
f a i l u r e before impact. The propeller blade
angles a t i m p a c t were in the positive pitch
r a n g e and both w e r e positioned about 40 de-
g r e e s . This indicated that both engines w e r e
developing appreciable power in nearly equal
amounts. The amounts w e r e n o r m a l f o r t h e
C onvair while circling to land.

Investigation and Evidence The radio and navigational equipment

Impact was i n an open muddy field a t
an altitude of 1 250 f e e t m e a n s e a level while
the a i r c r a f t was heading 220 d e g r e e s magnetic.
Evidence indicated that the a i r c r a f t was des-
cending about 1 600 f e e t p e r minute p r i o r to
impact. The m a j o r portion of the a i r c r a f t
was examined and although damaged failed to
disclose eviderxe of malfunction o r f a i l u r e
b e f o r e impact. Ground navigational facilities,
examined immediately after the accident, w e r e
operating within accepted tolerances. The a i r -
c r a f t a l t i m e t e r s w e r e found s e t and indicating
correctly. Y

* American Airlines1 procedure f o r s e t t l n g the two a i r ~ r d f ?a l t i m e t e r s ~ n d i c a t e sto the c r e w the

a i r c r a f t altitude both above mean sea l e v e l and above t i l t ; ;ti;purt of next ldnding. T h e captain's
i s s e t to r e a d altitude above the airpol t < i r ~ the
d f i s 5 t off;rerI.-,t,l iriean i e a level.
 ICAO Circular 50-AN/45 87

Supporting the physical examination of
the structure, powerplants, propellers, and
controls were the several radio contacts made
by the flight,, which were normal and indicated
no difficulty aboard the aircraft.
Radar impressions of the flight were in-
cluded on photographs taken by an Air Defense
Radar Installation near Springfield while com-
piling a r a d a r picture of the weather situation
and its progress, The r a d a r plotting indi-
cated that the average groundspeed of the a i r -
c r a f t after passing the VOR station was with-
in the normal range for Convair a i r c r a f t while
approaching an a i r p o r t before making a c i r -
cling approach.
There a r e t h r e e CAA approved instrument
approach procedures for the Springfield Air-
-
port the low frequency range approach, the
VOR approach, and an ADF ( ~ u t o m a t i cDirec-
tion Finder) approach. The VOR facility was
being used in this case. The VOR instrument
approach procedure associated with a flight
f r o m St. Louis requires that the a i r c r a f t turn
right upon reaching the VOR and establish an ,
outbound t r a c k of 13 degrees. It then r e -
quires a procedure turn and an inbound track
of 193 degrees, This track, if maintained,
will pass over the station again and intersect
the threshold position of Runway 19, which i s
7.8 statute miles from the station. Minimum
en route altitude from Vichy i s 2 600 feet
.
m. s 1. Minimum altitudes during the approach
a r e 2 600 feet m. s.1. over the station, 2 300
m. s. 1. during the procedure turn, and 1 867
m. s. 1. (600 feet above the airport) when over
the station inbound to the airport. The c i r -
cling minimum weather conditions for Amer-
ican Airlines' Convair flights a r e : Ceiling
500 feet and visibility 2 miles. The airport
field elevation i s 1 267 feet mean s e a level.
During the public hearing a company wit-
n e s s stated that under the circumstances he
believed the approach path depicted by the
r a d a r plots was in accord with the approved
VOR instrument approach procedure. He
stated that considering the degree of turn to
the a i r p o r t f r o m Airway 14, the distance in-
volved, and the en route altitude compared to
the specified minimum altitude for the airport,
the approach a s executed was a safe and r e a -
sonable interpretation of the VOR instrument
approach procedure. He believed the approach
was within the limitations imposed by the Civil
Aeronautics Administration and American
Airlines.
A Representative of the CAA, an Air
C a r r i e r Safety Agent assigned to the c a r r i e r
involved, stated that the approach indicated
by the r a d a r t r a c k of the flight was not con-
sistent with the requirements of the VOR in-
strument approach procedure. He stated
that the full procedure for Springfield, con-
sidering the facilities, is expected to b e com-
pleted when instrument conditions exist. He
said that the purpose of the outbound track,
the procedure turn, and the inbound t r a c k i s
to permit a flight to descend to a lower safe
altitude within a known area. These permit
the flight crew to establish a t r a c k to the a i r -
port with a facility check after that t r a c k has
been established and also afford the crew more
t i m e to complete final cockpit checks before
visual contact is made for landing. The testi-
mony of this witness was based upon Civbl Air
Regulations, Sections 60.46 and 40.364.
The captain, because of s e v e r e injuries,
was unable to remember any of the events of
the flight. He stated, however, that his in-
terpretation of the instrument approach would
not permit eliminating the outbound heading,
procedure turn, and the inbound t r a c k if in-
strument conditions prevailed.
During the entire flight and until the in-
stant of impact t h e r e was no warning of the
c r a s h o r indication of an emergency declared
in the passenger cabin.
Two passengers stated the flight between
St. Louis and Springfield was mostly above o r
between cloud l a y e r s and that during the l a t t e r
p a r t of the t r i p the engine power eound lessened,
and the a i r c r a f t descended and entered the

* 60.46 Instrument Approach Procedure. When instrument letdown i s necessary, a standard

instrument approach procedure specifically authorized by the Administrator shall b e used,
unless:
a) A different instrument approach procedure specifically authorized by the Administrator
i s used, or
b) A different instrument approach procedure i s authorized by Air Traffic c o n t r o l f o r the
particular approach, provided such authorization i s issued in accordance with Procedures
approved by the Administrator.

40.364 When an instrument approach i s necessary, the instru1ment approach procedures and
weather minimum authorized in the operations s p e c i f ~ c atons
t shall be adhered to.
88 ICAO Circular 50-AN/45
clouds which at times blotted out their view
of the wing light. They said that until the
a i r c r a f t descended below the clouds they could
not s e e any lights on the ground. Several
passengers said they saw widely scattered
ground lights through a light m i s t shortly
before the impact. One, seated on the left,
stated he saw lights to his left in the general
a r e a of the a i r p o r t one o r two minutes before
the crash.
Ground witnesses who saw o r heard
the a i r c r a f t believed i t was low compared to
other flights and all believed the sound of the
engines was normal.
After radio contact was established
with Springfield Approach Control the flight
was given an approach clearance which r e -
quired i t to r e p o r t upon reaching the VOR
station and when i t began the procedure turn.
Subsequent to this clearance the flight re-
ceived another which was "cleared for an
approacht1. This clearance, in effect, noti-
fied the flight there was no other traffic. It
also voided the reporting requirements and
permitted the flight to make any approach it
desired. The clearance, however, did not
permit or intend to permit any other approach
except the full instrument approach if instru-
ment conditions prevailed. F r o m the flight's
estimate t o the VOR station, i t s report over
the station, the time of the accident, and the
r a d a r plot i t i s clear the complete instrument
approach was not made.
Weather conditions in the Springfield
a r e a strongly indicate the top of the overcast
was between 3 000 and 4 000 feet mean sea
level and the overcast at the airport was with-
out breaks with i t s base about 500 feet above
the surface. Analysis of the situation also
suggests that these conditions prevailed in the
a r e a of the VOR station. It i s , therefore,
believed that the entire prescribed instrument
procedures should have been made. The
Board nevertheless recognizes the possibility
that the flight may have established visual con-
tact with the surface of the VOR station and
proceeded visually toward the airport. If the
crew did establish visual contact a t the mini-
mum en-route altitude before or upon reaching
the station i t was permissible for the flight t o
have proceeded visually to the airport without
following the instrument approach procedure.
* 1. Reference !'The Sensory Illusion of Pilots,
- Aircraft Accident Digest No. 4).
2. CAB Accident Investigation Reports, S A - 2 5 2 and SA-277.
ICAO Ref: ~ ~ / 3 8 2
This action would also have been permitted
under an emergency condition; however, based
on all the available evidence i t i s believed that
no emergency occurred.
F r o m the testimony of several eye-
witnesses i t i s apparent that the a i r c r a f t was
nearly on the 193-degree inbound radial to
the airport from the Ornni and that i t was
flown below the overcast for several miles
before it struck the ground. During this t i m e
the a i r c r a f t was in the same relative positions
over the ground required by the approved VOR
instrument approach procedure. F r o m the
evidence available during this segment the
a i r c r a f t was also apparently in the normal con-
figuration for an approach to the a i r p o r t before
circling to land. The height of the base of the
o v e r c a s t and the distance involved indicate the
r a t e of descent of the a i r c r a f t was not high
during most of this distance. However, just
prior to impact the a i r c r a f t was descending
about 1 600 feet per minute.
Evidence indicates that the crew was
not aware the a i r c r a f t was so low and that i t
was descending. It i s probable that a t this
time the pilots were devoting their attention
outside the cockpit and possibly toward the
distant airport lights while flying over flat,
dark, and sparsely lighted t e r r a i n in somewhat
r e s t r i c t e d visibility. An important psycho-
logical factor enters into an approach under
these conditions and has been credited a factor
in other accidents o r near accidents.* The
effect of such conditions has given flight crews
an erroneous impression of altitude and/or the
illusion that the a i r c r a f t i s flying horizontally
with respect to a distant light o r group of
lights when in reality the nose attitude of the
a i r c r a f t i s up o r down.
The likelihood of this situation relative
to the flight cannot be positively determined
because the p r i m a r y evidence of i t would be
provided by the crew's testimony, which was
unavailable to the Board. However, the simi-
larity of the circumstances of this and other
occurrences lends credence t o this explanation.
Probable Cause
The probable cause of this accident was
a descent to the ground while approaching the
a i r p o r t caused by the crew's ipattention to their
flight instruments and a possible sensory illu-
sion giving them an erroneous impression of
the attitude of the aircraft.
' by P.P. Cocquyt. (See ICAO Circular 3 8 - ~ ~ / 3 3
 ICAO Circular 5 0 - ~ ~ / 4 5 89

British European Airways Corporation, Vickers Viscount, G-AMOL,

crashed on landing at Copenhagen Airport, Kastrup, Denmark, on 25 March 1955.
Report of Directorate of Civil Aviation, Copenhagen, released 27 May 1955.

Circumstances ILS for Runway 12. Little by little, however,

The a i r c r a f t departed f r o m iondon atthe pilots preferring to use Runway 22, even
1518 hours on a scheduled flight - London/
-
~ o ~ e n h a ~ e n / ~ t o c k h o lcarrying
rn a crew of
5 and 33 passengers. The flight to holding
position over the Beacon Saltholm Flak (SF)
at Kastrup was c a r r i e d out according to sched-
ule. During a 15-minute holding period the
aircraft was cleared through different heights
down to 1 500 feet. The ILS approach to Run-
way 22 was made by the captain. At 350 - 400
feet he sighted the runway lights and perform-
ed the remaining part of the landing procedure
with visual reference to the ground. The a i r -
craft was then to the left of the runway and a s
the captain attempted to manoeuvre it into the
centre line of the runway the a i r c r a f t drifted,
touched down and proceeding in a direction of
240 degrees (runway direction = 223 degrees) .
wheeled outside the boundary of the runway,
collided with a snowbank and finally came to a
standstill a t the northern edge of the runway.
NO persons were killed or injured, however,
the a i r c r a f t was substantially damaged.
Investigation and Evidence
No evidence was found of faulty material
o r any indication of fatigue fracture.
A thorough examination was not made of
the load acting on the nose gear/port main
g e a r , due to which loading they were torn off.
It i s deemed, however, that the dimensioning
of the undercarriage does not permit the heavy
side load to which i t was subjected.
the a i r c r a f t due to land changed t o Runway 22,
though the wind there was rather unfavourable.
The reason for this action must most likely be
sought in the fact that the ILS f o r Runway 12
had only been officially approved on 14 March
1955 s o that the majority of the airline compa-
nies operating on the Copenhagen Airport had
not a t the time of the accident entered this
facility in their route manuals. Both the ILS
for Runway 22 and the ILS for Runway 12 were
serviceable on the day of the accident.
According to statements by captains of
other approaching aircraft and the MET Office,
vertical and horizontal visibility was variable.
One captain reported:
'1 estimate the winds to have been 160/35
knots at 1 500 feet backing and decreasing
to 110/20 knots a t 200 feet, with a s h a r p
change a t 500 feet.
The l a s t part of the approach was espe-
cially difficult due to the sudden change
in wind velocity giving an approximate 9
degree change of drift, and the change
f r o m slight headwind to slight tailwind
component ."
This varying force of the c r o s s wind
during the descent f r o m 1 5 0 0 feet must be
presumed to explain why the a i r c r a f t in question
was to the left of Runway 22 when the captain
got visual reference to the ground, notwithstand-
ing the wind reported f r o m the ground.

The chart of the force and direction of F o r landings with Viscount, BEA accept
the wind for the period in question shows a a maximum c r o s s wind component of 30 knots.
marked stability. The reported wind, 130 "/13 knots, was thus
well below what was permissible f o r a landing
According to ATC, the noon and a f t e r m n on Runway 22.
traffic handled on the day in question took place
on Runway 12. In the course of the afternoon There was no indication that the BEA
the wind shifted f r o m 170 to 140 degrees, i t s weather minima had not been observed.
force varying between 8 and 12 knots. The
weather deteriorated, visibility decreased The information available did not reveal
f r o m 7 km to between 2 and 1.3 km and the anything to indicate that the ILS for Runway 22
height of cloud base f r o m 150 metres to be- was not working satisfactorily. The procedure
tween 90 and 60 metres. Under the prevailing prescribed for an ILS approach to Runway 22
wind conditions i t would have been reasonable was to all appearances applied in the normal
to make the approach f r o m the northwest on the way. It was not possible to a r r i v e a t an exact
 90 ICAO Circular 5 0 - ~ ~ / 4 5
position-fixing of the a i r c r a f t a t the time when
the pilots in the cockpit got visual reference to
the runway. It was established that the aircraft
was to the left of the runway (outside of the
lights along the left edge of the runway) a t the
time in question. This caused the a i r c r a f t to
make a right turn which, according to two of
the passengers, was very steep. During this
turn, the aircraft, owing to the prevailing wind,
was subjected to a drift to starboard which ne-
cessitated a correcting turn to port in o r d e r to
line up the a i r c r a f t with the centre line of Run-
way 22, In the course of this procedure the
port main wheels of the a i r c r a f t touched the
runway a t 495 metres f r o m the threshold of the
runway and 23,9 metres f r o m the northern edge
of the runway.
It was fully established that the a i r c r a f t
was s e t down on the runway in a way deviating
f r o m normal procedure.
ICAO Ref: ~ ~ / 3 6 3
-
It was not possible on the information
available to give any definite opinion a s to wheth-
e r it was justifiable under the prevailing wind
conditions to undertake a landing f r o m the point
where the captain obtained visual reference t o
the runway. There was nothing in the facts
brought forward to give any cause for disputing
the correctness of the captain's judgment and
decision to land.
Probable Cause
The pilot deviated f r o m the normal proce-
dure and failed to bring the a i r c r a f t into align-
ment with the runway fromiits position at the
time when he obtained visual reference to the
runway.
Vlcksra VCacomt Q-AMOL at ssrl oxl Rmwrxy 25 arft"rrss crash
-
on Imcllng rt GopasrJirsaca Airport, Denmark 2% March 1945.

Figure b l
Impression *a snow bank nrade by nose gear and l e f t main
gear wheels,
92 ICAO Circular 5 0 - A ~ / 4 5
No. 16
Circumstances
The scheduled flight f r o m Seattle-Tacoma,
Washington, to Sydney, Australia, departed
Seattle-Tacoma Airport a t 0815 hours Pacific
Standard Time for Portland, Oregon, the f i r s t
intermediate stop. On board were 13 passengers
and 8 crew members and two additional passen-
g e r s boarded the a i r c r a f t a t Portland. At 1010
the flight left the r a m p a t Portland, taking off for
Honolulu, T e r r i t o r y of Hawaii a t 1021 on an I F R
clearance. The flight plan was via Newberg and
Newport, Oregon, thence to Honolulu to cruise
at 10 000. Forty two minutes after take-off
s e v e r e vibration occurred while cruising at
10 000 feet under VFR conditions. No. 3 engine
and propeller then tore f r e e and fell f r o m the
a i r c r a f t and control difficulties followed. Effec-
tive control was regained after rapid l o s s of
considerable altitude and the a i r c r a f t was ditch-
ed under control a t 1112 hours approximately 35
miles off the Oregon coast under near ideal s e a
conditions. All 23 occupants were evacuated
but four fatalities and one serious injury occurred..
The a i r c r a f t sank after an estimated 20 minutes,
in water about one mile deep.
Investigation and Evidence
Immediately following the loss of No. 3
engine and propeller the captain disconnected
the autopilot. Severe buffeting ensued, the nose
went down and the a i r c r a f t swung to the right
sharply. At this point, the emergency "Mayday"
signal was broadcast on both VHF and HF. Di-
r e c t return to Portland was authorized by Seattle
Air Route Traffic Control.
Airspeed was about 220 knots and going
higher s o the captain closed the throttles to keep
the airspeed down. He still could not get the
nose up a n d i t felt to him a s though the elevators
weye still on automatic pilot. He then tried the
elevator t r i m tab and could not turn it.
After rapid l o s s of altitude t o about 5 000
feet, the captain directed the f i r s t officer to
a s s i s t him with the controls. Their combined
efforts finally brought the nose up very rapidly
but the aircraft then went into a steep climb.
It turned sharply to the right about 180 degrees
anQ, according to the captain, appeared to be
on "the verge of a spin." Level attitude was r e -
gained by pushing the yoke forward, and by use
of the rudder and aileron t r i m the turn wan
stopped. At an airspeed of 150 knots, flaps
extended 25 degrees, buffeting decreased im-
mediately, however, the a i r c r a f t continued t o
descend rapidly. Attempts to get rated power
were futile and a t approximately 1106 hours a
message was broadcast that ditching was im-
minent. Contact with the water 6 minutes
later was severe, and the impact dislodged
life rafts f r o m their storage bins and some
seats were torn loose. Evacuation was orderly
and the three rafts, although dislodged f r o m
their stowage receptacles, were launched
without undue delay.
Because the failure originated in the
No. 3 engine or propeller, followed very
quickly by that power package wrenching f r e e ,
investigation was aimed a t ascertaining the
nature of the malfunction and reason f o r the
failure.
Loss of the engine and propeller could
have been caused by, (1) failure of the engine
mount, (2) sudden stoppage o r seizure of the
engine, o r (3) an unbalanced propeller caused
by failure of a blade. Since the engine and
propeller could not be recovered there was no
opportunity to examine them.
The f i r s t possibility - failure of the
engine mount - s e e m s unlikely a s testimony
indicates that when the engine left it took its
mount with i t leaving nothing forward of the
firewall except small parts such a s wires and
lines .
Regarding the second possibility - that
of sudden engine stoppage o r seizure - inves-
tigation disclosed that there have been no known
cases in which an engine has torn f r e e f r o m
this model a i r c r a f t a s a result of sudden
stoppage.
The third possibility - en unbalanced
propeller - must, therefore, be the cause of
the failure. Other blade failures of this pro-
peller -engine combination have produced
similar results.
There have been five previous instances
of total powerplant separation from like a i r -
c r a f t and one of partial separation. Of these
 ICAO Circular

six , two were definitely caused by propeller The propeller speeds of the a i r c r a f t were
blade failure, and the remaining four (where electrically controllable. Control could be in-
engines were not recovered) undoubtedly r e - dividual o r simultaneous. The electrical sys-
sulted f r o m the same cause. tem employs fuses for the four individual engine
circuits and master circuit b r e a k e r s , both of
which a r e common to a l l four circuits. One
During the service life of this propeller, master circuit breaker i s in the automatic syn-
the manufacturer developed modifications and chronization circuit and the second one i s in the
more restrictive inspection and maintenance circuit for manually selecting engine r . p . m.
procedures, a l l of which were aimed at improv- In this instance, the tearing away of No. 3 engine
ing the integrity of the blade. The most recent obviously created a short in that portion of the
modification was to nickle-plate the blade s u r - system serving No. 3 engine. A subsequent
face to minimize service-incurred nicks and attempt by the flight engineer to increase r. p. m.
gouges. Blades on the PAWA fleet of B-377 by use of all switches simultaneously (for rated
aircraft were nickle-plated and maintained in power) resulted in opening of the master circuit
accordance with the manufacturer's latest s e r v - breaker s o that the r . p . m. of none of the re-
ice instructions. maining t h r e e engines could be changed. Testi-
mony indicates that the engineer closed the
The investigation of this accident included circuit breaker and again attempted unsuccess-
a study of the results of special inspections that fully to get simultaneous increase of r . p. m.
were initiated subsequent to the accident to de- By this time the a i r c r a f t was nearly to the water.
termine the integrity of service blades. These The captaln stated that the r.p. m, never in-
inspections included X-ray, magnaflux, and creased.
detailed visual examinations of blades external-
ly in a r e a s normally not readily accessible, The flight engineer attended two c l a s s e s
i. e . , under rubber fairings. Hitherto this a r e a in 1955 on propeller control circuity. It has
had not been suspect. been established, however, that the specific
contingency that occurred in this accident was
This comprehensive program disclosed never taught in any of these c l a s s e s , nor had
nicks and gouges beneath the g a r t e r caused the company issued any specific instructions in
during a manufacturing operation following regard thereto. Nor could this particular type
plating. Furthermore, a s the program proceed- of situation be approximated precisely in the
ed, a cracked blade, not nickle-plated was Dehmel flight engineer simulator course.
found on the a i r c r a f t of another c a r r i e r . Study
of this crack revealed that it resulted f r o m The assistant flight engineer, who was
fatigue and that it originated a t a corroded a r e a occupying the jump seat at the s t a r t of the e m e r -
under the rubber fairing, gency, stood for a while behind the engineer and
observed that the a i r c r a f t Is behaviour was simi-
Until the date of the accident, no cracks l a r to that previously described; i. e. heavy
had been reported a s being found on nickle- aerodynamic buffeting and difficulty of the cap-
plated blades. However, the intensive inspec- tain and copilot in controlling the a i r c r a f t . He
tion program revealed three cracked model recalled that the three engines were running
2J17 blades that were associated with corrosion smoothly.
and one blade failed f r o m the same cause while
undergoing fatigue testing a t the factory. The At this point the assistant flight engineer
X-ray program revealed one new blade a t PAWA suggested to the flight engineer that the pilots
cracked beneath the rubber boot. This crack would have l e s s difficulty in raising the right
had occurred during blade manufacture but had wing if he would give them more power f r o m
remained undetected. No. 4 engine. The flight engineer replied that
he was unable to get any r . p. m. change. The
Corrosion which i s known often to s e r v e assistant flight engineer then reached over and
a s foci for fatigue failure was found on 13.5% advanced No. 4 throttle several inches. At
of the PAWA-Pacific-Alaska Division blades. this time he observed the altimeter reading to
be 600 feet.
The routine in transit service mainte-
nance on the subject aircraft a t Portland con- The assistant flight engineer then watched
sisted of a visual inspection of propellers, the flight engineer actuate the propeller toggle
landing gear wheels, t i r e s , control surfaces, switches, also with no effect, saw him r e s e t
engine cowling, etc. The inspection was made the propeller control circuit b r e a k e r s , and then
by two mechanics, who found no imperfections. he went to the passenger cabin f o r ditching.
 94 ICAO C u r c u l a r

The manufacturer of this a i r c r a f t had a f a b r i c b r a i d e d s t r a p which was m o r e r e a d i l y

p r e p a r e d performance c u r v e s f o r three-engine
t the Boeing 37'7. T h e s e p e r f o r m a n c e
f l ~ g h of
c u r v e s w e r e b a s e d upon a c t u a l flight t e s t s and
wind tunnel t e s t s of the a i r c r a f t t o v e r i f y flight
conditions that e x i s t r d following the l o s s of No. 4
engine f r o m a s i s t e r ship. * The c u r v e s depict
the flyability of this model a i r c r a f t with No, 3
t o r n f r e e , a s happened in the subject case. They
show, assuming landing g e a r up, f l a p s extended
25 d e g r e e s , a n a i r s p e e d of 130 knots, which i s
the a i r s p e e d f o r minimum power r e q u i r e m e n t s ,
t h a t the a i r c r a f t , g r o s s i n g 131 000 pounds, would
have been flyable at take-off power, 2 7000 r.pm
(131 000 pounds i s the computed g r o s s weight
a f t e r s e p a r a t i o n of the No. 3 power package.)
T h e s e deductions by t h e manufacturer a r e p r e m -
i s e d upon t h e r e being no s t r u c t u r a l deformation
of the a i r c r a f t ( a s f r o m impact by p a r t o r p a r t s
at t i m e of failure). If s u c h existed, additional
power r e q u i r e m e n t s of unknown d e g r e e , would
have been imposed.
Testimony a l s o indicates that the subject
a i r c r a f t would r e q u i r e a weight reduction of
11 000 pounds to r e a c h 120 000 pounds, the weight
n e c e s s a r y to s u s t a i n l e v e l flight in the vicinity
of s e a l e v e i with the power obtainable a t 2 040
r. p. m.
The captain testified that p r i o r to extending
flaps a b ~ u one
t minute b e f o r e ditching t h e r e was
not even sufficient t i m e to consider dumping fuel.
The t h r e e 20-man life r a f t s w e r e loaded
with 13, 5, and 2 occupants. The n e a r e s t r a f t
to any of the t h r e e p e r s o n s who w e r e not r e s c u e d
was estimated to b e 100 f e e t o r m o r e . The heav-
ing l i n e s in a l l t h r e e r a f t s w e r e 25 f e e t long.
Two of the life r a f t s w e r e of one make, the
t h i r d of another. The f i r s t two had l e s s distinct
and m o r e limited stenciled instructions f o r u s e
than had the third. C r e w m e m b e r s w e r e a c -
quainted with t h e s e instructions but p a s s e n g e r s
w e r e not and consequently w e r e handicapped in
t h e i r efforts t o a s s i s t in r e s c u e efforts.
seen.
T h e s e r a f t s had inflatable c e n t e r c h a m b e r s
t o p r o v i d e e x t r a buoyance, rigidity, and t o
prevent occupants f r o m sliding toward the cen-
t e r . The c e n t e r c h a m b e r s had to b e inflated
a f t e r launching with a hand pump c a r r i e d in the
raft. Until this was done, occupants s l i d toward
the c e n t e r because it w a s d e p r e s s e d and the
s u r f a c e was oil covered. Moreover, the action
of occupants slipping toward the c e n t e r r a i s e d
the r i m which made boarding even m o r e difficult,
and prevented those in the r a f t f r o m helping
p e r s o n s in the water. The equipment b a g s con-
taining paddles, heaving l i n e s , etc. , are-outside
the r a f t a f t e r inflation, and it i s n e c e s s a r y to
r e a c h the edge of the r a f t to r e c o v e r them.
Both p a s s e n g e r s and c r e w m e m b e r s t e s -
tified that the evacuation was o r d e r l y and con-
ducted i n a n expeditious m a n n e r , with the ex-
ception of the difficulty h e r e t o f o r e mentioned.
P a n A m e r i c a n had a n established A i r c r a f t
E m e r g e n c y Equipment Training C o u r s e f o r c r e w
m e m b e r s . P r i o r to taking this E m e r g e n c y
Equipment training a l l flight personnel m u s t
have completed a c o u r s e of a i r c r a f t familiariza-
tion, including a complete knowledge of the a i ~
craft's doors, emergency exits, etc.
The flight was under surveillance of ground
r a d a r . A plot of i t s o b s e r v e d positions confirms
the c r e w ' s testimony a s to the a i r c r a f t ' s ma-
noeuvres while descending. It shows, specifi-
cally, that s t a r t i n g f r o m cruising altitude of
10 000 f e e t on a southwesterly c o u r s e , the a i r -
c r a f t made a full 360-degree t u r n to i t s right
and then turned r a t h e r s h a r p l y about 180 d e g r e e s ,
a l s o to i t s right, and was then l o s t t o the r a d a r
a s it went below 500 feet. ( J u s t p r i o r to ditch-
ing. ) The direction of ditching was about oppo-
s i t e that of tiie initial c r u i s i n g flight; about a
full t u r n and a half to the right was made between
the s t a r t of the trouble and the ditching; the
total elapsed t i m e was r e c o r d e d a s nine minutes.

The f i r s t two r a f t s had s m a l l nylon life- Analysis

l i n e s , extending completely around the outside
c i r c u m f e r e n c e , to a s s i s t in boarding. P a s s e n - a ) Initial f a i l u r e
g e r s s t a t e d this c o r d was not visible a f t e r being
coated with oil on the water. The third r a f t had The vibration which o c c u r r e d immediately
before No. 3 power package wrenched f r e e fol-
lowed a f a m i l i a r pattern of known propeller
* See Civil Aeronautics B o a r d Accident Investi- blade f a i l u r e s . D e s p ~ t ethe power package not
gation Report, PAWA, between Honolulu and being r e c o v e r a b l e , the B o a r d had no r e a s o n to
Wake Island, 6 December 1953. (ICAO C i r c u l a r doubt that the trouble was due t o blade failure.
3 9 - A ~ / 3 4 - A i r c r a f t Accident Digest N a 5 , Report This belief was based on the known h i s t o r y and
No. 35) subsequent examination of model 2 J17 blades.
 ICAO C i r c u l a r
This basic blade i s , a s demonstrated by
i t s s e r v i c e history, prone to c r a c k a t surface
i r r e g u l a r i t i e s . This fact dictates meticulous
inspection during manufacture and while in
service.
b) Control difficulty
The Board was unable to d e t e r m ~ n ethe
reason for the initial control difficulty, It may
have been aggravated by a n indeterminable
i r r e g u l a r i t y of a i r flow over the empennage
caused by the l a r g e , flat plate a r e a of No. 3
firewall. It may a l s o have been due to s o m e
deformation of the a i r f r a m e , particularly of
the empennage, caused by some violently slung
object o r objects f r o m the No. 3 power package.
This possibility i s strengthened by the difficulty
the pilot had in moving the yoke which n e c e s s i -
tated h i s calling on the f i r s t officer f o r a s s i s t -
ance. However, no impact a t the time of o r
immediately a f t e r the failure was sensed by
any occupant.
c) Inability to i n c r e a s e r. p. m. of other t h r e e
engines
The flight engineer on duty a t the time of
the accident did not survive. Consequently, the
nature of the difficulty that he experienced in
attempting to i n c r e a s e engine speeds can only
be learned f r o m other testimony. There was
no evidence that t h e r e was mechanical o r elec-
t r i c a l impairment of the control s y s t e m of Nos.
1, 2, and 4 propellers. T h e r e had been no
trouble of any s o r t p r i o r to the emergency. In
view of the known c h a r a c t e r i s t i c s of the protec-
tive devices in the propeller control circuity,
i t can be concluded that the inclusion of the No.
3 toggle switch in the simultaneous actuation of
the toggle switches was the responsible factor
in not getting i n c r e a s e d r . p, m.
Effective a s of approximately 20 April
1955 the 10 amp. magnetic circuit b r e a k e r s were
replaced by slower acting 5 amp. t h e r m a l type
circuit b r e a k e r s in both m a s t e r c i r c u i t s and accident resulted in a number of c o r r e c t i v e
the 5 amp. fuses in the individual circuits w e r e m e a s u r e s being initiated, among which were:
replaced by 2 amp. fuses. This change allows
the fuse associated with the malfunctioning
circuit to blow and thus leave the remaining
c i r c u i t s unaffected. This modification was de-
tailed in Hamilton Standard Service Bulletin
No. 283.entitledI "Synchronizer Toggle Switch
Circuit Protection, ' I dated 21 December 1953.
Compliance with this bulletin was not mandatory 3)
by the CAA although the importance of i t s text
was effectively demonstrated by the c i r c u m -
stances of this accident and it was made man-
datory by the CAA on 21 April 1955. It may be
polnted out that this modiftcation was a l s o ap-
plicable to the c a r r i e r ' s fleet of Douglas DC-6's
and had been made on them; ~t was the compa-
n y ' s ~ n t e n tto make s i m i l a r modifications on i t s
fleet of Boeing 377's a s soon a s practicable.
d) Nondumping of fuel
Engineering opinion i s that the subject
a i r c r a f t would have been flyable with No. 3
engine gone a t 2 040 r. p. m. had i t s weight
been reduced to a g r o s s of 120 000 pounds. This
would have required a weight reduction of ap-
proximately 11 000 pounds. The maximum r a t e
of fuel flow during dumping a t 165 knots indi-
cated i s approximately 2 160 pounds p e r minute.
Thus i t would have taken slightly m o r e than five
minutes t o lose 11 000 pounds; f r o m initial dif-
ficulty t o ditching was approximately nine min-
utes.
It a p p e a r s that if fuel dumping could have
been s t a r t e d immediately after the f a i l u r e the
a i r c r a f t could have been lightened rapidly enough
to have been m o r e flyable on the t h r e e good
engines. However, the captain's t i m e was oc-
cupied in attempting to control the a i r c r a f t and
the problem of the inability t o i n c r e a s e r . p. m.
e ) Ditching
The a i r c r a f t was ditched in daylight under
n e a r ideal s e a conditions. This was the f i r s t
ditching of a civil B-377 a i r c r a f t , consequently,
t h e r e was no d i r e c t knowledge of i t s ditching
c h a r a c t e r i s t i c s . The a i r c r a f t remained afloat
f o r approximately 20 minutes.
I Under these favorable c i r c u m s t a n c e s and
with comparatively few passengers (15) i t might
be anticipated that little difficulty would be ex-
perienced in getting everyone aboard life r a f t s .
Such was riot the case.
f ) Corrective action
The o c c u r r e n c e and investigation of this
1) Life rafts were stowed more s e c u r e l y .
Additional inspections of the propeller
2)
blades w e r e required and the periods
between previously required inspections
were ~ r some
! instances shortened.
The schedule of installation of propeller
blade imbalance detectors which had p r e -
viously been developed to warn the c r e w
of an impending blade failure was expe-
dited and their use made mandatory by the
96 ICAO Circular 50-AN/45
CAA a s of 30 July 1955.
4) The manufacturer resumed development
of a solid aluminum propeller blade for
use on B-377 aircraft. The CAB recom-
mended to the CAA that all Hamilton
Standard 2517 hollow steel blades be re-
moved f r o m service on the B-377 aircraft
at the e a r l i e s t possible date consistent
with the manufacturerls ability to supply
satisfactory blades.
5) The Administrator, by letter dated 28 June
1955, advised operators of the B-377 a i r -
craft a s follows:
"As a result of this investigation, and
of the investigations conducted follow-
ing six other accidents o r serious in-
cidents, we have concluded that, in the
interest of safety, the Hamilton Stand-
a r d Model 24260 propellers having
2517 s e r i e s hollow steel blades pres-
ently used on Boeing 8-377 a i r c r a f t
should be removed f r o m service and
replaced with propellers having solid
metal blades. This shall be done at
ICAO Ref: A R / ~ O O
the e a r l i e s t possible date consistent
with the ability of the propeller manu-
facturer to supply satisfactory blades."
6) Special inspections a s determined to be
required were made mandatory by the
Administrator, f i r s t by telegraphic a l e r t s
and subsequently by Airworthiness Direc-
tives dated 11 April 1955, 6 June 1955 and
10 October 1955.
Development of solid aluminum alloy blades
suitable f o r use on the Boeing B-377 has been a
high priority project with the manufacturer,
Hamilton Standard. As of 20 October 1955 four
slightly differing experimental propellers have
been built. Flight testing i s required, and is
scheduled for the immediate future, to deter-
mine the best of the four.
Probable Cause
The probable cause of this accident was
loss of control and inability to maintain altitude
following failure of the No. 3 propeller which
resulted in wrenching f r e e No. 3 power package.
 ICAO Circular 5 0 - A ~ / 4 5
No. 17
-
Slkorsky 5-55 h e l i c o p t e r c r a s h e d s h o r t l y a f t e r taklng off f r o m Burgeo, Newfoundland,
on 28 M a r c h 1955. Canadlan D e ~ a r t m e n tof T r a n s p o r t R e p o r t NO. 55-15.
At approximately 1520 NST on 2 8 M a r c h
1955 the Sikorsky S-55 a i r c r a f t left Burgeo f o r
St. J o h n ' s Newfoundland, on a non-scheduled
c o n t r a c t flight wlth one pilot and four p a s s e n -
g e r s on b o a r d .
About five minutes a f t e r taking off a d v e r s e
weather conditions w e r e encountered and the
pllot decided to r e t u r n t o Burgeo. When withln
one m i l e of the n o r t h of B u r g e o the a i r c r a f t w a s
c r u i s i n g smoothly and n o r m a l l y when a sudden
r a p i d r a t e of s i n k developed. The pllot a t t e m p t -
ed to land the a i r c r a f t on the top of a hill but
due t o the r a t e of d e s c e n t the a i r c r a f t r e c e i v e d
substantial d a m a g e when ~ t s t r u c k the ground In
an upright attitude and then toppled o v e r onto ~ t s
s i d e . Neither the pilot n o r p a s s e n g e r s w e r e
injured.
I n v e s t ~ e a t l o nand Evidence
T h e r e was no evidence of malfunctioning
of the engine, a i r f r a m e o r c o n t r o l s . The c a r -
b u r e t t o r h e a t c o n t r o l was found to be s e t a t
about t h r e e - q u a r t e r s of l t s t r a v e l to the full hot
position.
The r o t o r b l a d e s did not s t r i k e the t a i l
cone immediately following ~ m p a c tindicating
that the a i r c r a f t landed with the b l a d e s a t a hlgh
coningY6angleand that power was s t i l l being de-
livered a t the t i m e of i m p a c t .
The pilot held a Senlor C o m m e r c i a l P l l o t
Llcence whlch was valid a t the t i m e of the a c c i -
dent and had a c c u m u l a t e d a total of 6 000 h o u r s
of flying e x p e r i e n c e of which 700 h o u r s had been
a c q u i r e d on h e l i c o p t e r s and 150 llours had been
obtalned on S i k o r s k y 5-55 type of a i r c r a f t .
* --
'The a v e r a g e dngle between the span ~ X I Sof a blade o r wlng of a r o t a r y wlng s y s t e m
and a plane p e r p e n d i c u l a r to the ax15 of rotation.
I GAO R e f : ~ ~ / 3 9 4
97
The flow of a i r a t the t i m e of the a c c i d e n t
was f r o m t h e n o r t h and it would, t h e r e f o r e , have
been flowing f r o m the c e n t r e of Newfoundland to
the south c o a s t . Under t h i s condition, c o a s t a l
ccnditions would be b e t t e r than t h o s e inland.
The rugged country in the a r e a of the c r a s h
would not only be conducive to v e r y t u r b u l e n t
a l r and p o s s i b l y r a t h e r s h a r p downdrafts but
a l s o to ragged cloud b a s e s and p o s s i b l y s o m e
m o d e r a t e snow f l u r r i e s .
f h e weather i n the afternoon w a s r e p o r t -
ed a s o v e r c a s t a t 1 5 0 0 f e e t with v i s i b i l i t y 6 to
8 m i l e s in h a z e and o c c a s i o n a l light snow.
After the take-off, the w e a t h e r w a s s a i d t o
have d e t e r i o r a t e d wlth h e a v l e r snow and r e -
duced vlsibillty.
The likelihood of t h e sudden r a p i d de-
s c e n t belng due t o a downdraft i s discounted
a s the a i r c r a f t w a s o n the n o r t h w e s t s i d e of
the hill and the wind was f r o m the n o r t h w e s t
a t 15mph.
The t e m p e r a t u r e and dewpoint i n the
a r e a of the a c c ~ d e n ta r e not known but Stephen-
ville r e p o r t e d the t e m p e r a t u r e a s 33 O F . a n d
the dewpoint a t 31°F. and o t h e r r e p o r t i n g
s t a t i o n s showed a d i f f e r e n c e of 4 " and 5 " be-
tween the t e m p e r a t u r e and humidity. Condl-
tlons conducive t o c a r b u r e t t o r iclng a r e , there-
f o r e , believed to have been p r e s e n t .
P r o b a b l e Cause
F o r r e a s o n s that w e r e not conclusively
d e t e r m i n e d , the a i r c r a f t developed a rapid
r a t e of d e s c e n t and s t r u c k the ground In an
upright attltude d u r i n g the f o r c e d landing that
ensued.
 98 ICAO C i r c u l a r 5 0 - ~ N / 4 5

No. 18

United A i r Lines, Inc.. DC-6 a i r c r a f t , c r a s h e d a t MacArthur Field,

Islip, N. Y. , on 4 April 1955.
Civil Aeronautics Board (U.S. A . ) Accident Investigation Report NO. SA-306,
F i l e No. 1-0071, r e l e a s e d 4 October 1955,

Gircumstances of Runway 32 and 321 feet f r o m the north edge

Under the command of the UAL New York
a r e a flight manager the a i r c r a f t departed New
York International A i r p o r t a t 1428 h o u r s East-
e r n Standard T i m e on a Visual Flight Rules
flight plan f o r an estimated two hour flight in
the vicinity of MacArthur Field. Two captains
were aboard to receive their periodic instru-
ment proficiency check. On completion of the
checks the flight was scheduled to r e t u r n to La
Guardia. The flight reported a t 1501 that "they
were doing a i r work around Hempstead" and
s h o r t l y a f t e r 1527 requested approval f o r a n ILS
( ~ n s t r u m e n Landing
t System) approach and land-
ing a t Islip ( M a c ~ r t h u rField) which were c a r -
ried out. The controller then c l e a r e d the flight
to take position on Runway 32 and take-off c l e a r -
a n c e s were transmitted a t 1548 and 1550, * engaged, and a l l mixture controls w e r e found
Take-off and initial climb appeared n o r m a l and
the a i r c r a f t remained on the runway heading.
When about 50 feet high the right wing lowered
and the a i r c r a f t s t a r t e d turning to the right a s
the landing g e a r was retracting. The climbing
t u r n was continued and the degree of bank in-
c r e a s e d to approximately v e r t i c a l by the t i m e
the heading changed about 90 d e g r e e s and the
a i r c r a f t had attained a n estimated altitude of
150 feet. The nose dropped s h a r p l y and the
a i r c r a f t dived into the ground, cartwheeled and
c a m e to r e s t right side up. All t h r e e occupants
were killed and intense f i r e consumed a l a r g e
portion of the wreckage i n spite of prompt a r -
rival of f i r e fighting equipment.
Investigation and Evidence
The MacArthur weather observation a t
1532 hours showed s c a t t e r e d clouds a t 20 000
feet, broken clouds a t 25 000; visibility over 15
miles; t e m p e r a t u r e 53; dewpoint 30; wind N N W
a t 20 knots; gusts to 30 knots.
The wreckage was quite localized. The
main portion was 173 f e e t f r o m the e a s t edge
of Runway 24, about 1 300 feet f r o m where it
became airborne. F o r w a r d of the front cabin
bulkhead, the fuselage s t r u c t u r e was destroyed,
but the s e a t belts held.
E a r l y in the investigation, the g e n e r a l
integrity of the fuselage, wing, and control
s u r f a c e s was the subject of careful examina-
tion to determine i f any malfunction o r f a i l u r e
o c c u r r e d during take-off. No malfunction o r
fzilure was indicated by these examinations.
The landing g e a r was r e t r a c t e d a t impact and
the flaps were extended 15 to 20 d e g r e e s (nor-
m a l f o r take-off). The automatic pilot was
disengaged. All t r i m tabs w e r e in place on
their hinges and no evidence of f a i l u r e o r mal-
functioning was noted. The gust lock was dis-
in auto rich; these positions were n o r m a l f o r
take-off. No evidence of malfunction o r fail-
u r e in any of the flight control s y s t e m s was
found.
No evidence of f a i l u r e in operation was
found in any of the engine wreckage. Exami-
nation of the propellers indicated that each
engine was developing power a t impact, though
the degree of power output could not be a s c e r -
tained.
The propeller governors were position-
ed f o r take-off r . p. m. No. 4 propeller was
rotating in i t s n o r m a l direction a t impact but
in r e v e r s e pitch. The No. 4 propeller s h i m
plates showed that i t was in f i l l Geverse pitch,
o r minus eight d e g r e e s . Nos. 1, 2, and 3
propellers were found a t 34 degrees positive
pitch, normal f o r take-off. Examination of
a l l four propellers disclosed no evidence of
faulty operation.
Examination of a l l e l e c t r i c a l units con-
cerned with control of No. 4 propeller disclos-
ed no evidence of operational malfunction o r
failure.

* It i s the custom of U A L pilots on check flights to make a final check of significant i t e m s a f t e r

taking position, before starting a simulated instrument take-off.
 ICAO Circular 50-AN/45
The propellers of the DC-6 a i r c r a f t may
be used to provide r e v e r s e thrust for braking
while the a i r c r a f t i s on the ground. Propeller
reversal i s initiated by retarding the throttles
aft of the forward idle position at which time an
electrical control system i s activated causing
the blades of the propellers to rotate within their
hubs to a position wherein r e v e r s e thrust i s de-
veloped . The extent of engine power and r e v e r s e
thrust developed i s in proportion to the extent of
rearward throttle movement. The propellers
are unreversed and forward thrust i s restored
by returning the throttles to the forward idle
position o r beyond.
While the a i r c r a f t i s airborne a throttle
latch mechanism prevents inadvertent throttle
movement aft of the forward idle position and
thus prevents unwanted reversal. Operation of
the throttle latch i s controlled by switches, on
the landing gear struts, that close when the a i r -
craft's weight i s on the landing gear. This ac-
tion energizes a solenoid which in turn releases
the throttle latch. At the s a m e time the r e v e r s e
warning flag swings up into view on the control
pedestal to show that the latch i s out of the way.
Mechanically linked to the solenoid, this red
metal flag may be raised manually by the crew
to operate the latch should the solenoid fail to
operate.
When the aircraft becomes airborne the
strut switches open and the solenoid becomes
de-energized. The latch returns to the locked
position and the flag swings down out of sight.
Approximately three years ago United
Air Lines, concerned over the possibility of an
unwanted inflight propeller r e v e r s a l due to an
electrical malfunction, modified the propeller
control circuits of its DC-6 fleet. This modifi-
cation results in the automatic removal of elec-
trical power f r o m the circuits controlling pro-
peller r e v e r s a l whenever the aircraft i s a i r -
borne. Electrical power i s restored to these
circuits when the a i r c r a f t i s on the ground. Re-
moval and restoration of electrical power i s ac-
complished automatically through the addition
of a relay (known a s the H-relay) controlled by
switches which a r e in turn actuated by the throt-
tle latch solenoid. The propeller control circuit
of the subject a i r c r a f t had been so modified.
Investigation disclosed that once a pro-
peller s t a r t s into r e v e r s e position it need not
cycle completely but can be unreversed f r o m
99
any negative blade angle. Should the propeller
become reversed due to movement of the throt-
tle rearward past the forward idle position,
while the a i r c r a f t is on the take-off run and,
should the a i r c r a f t then become airborne in
this configuration, the propeller may be un-
reversed by (1) feathering o r (2) lifting the
r e v e r s e warning flag and advancing the throt-
tle. Raising the flag s e r v e s the same function
a s the landing gear switch when the a i r c r a f t i s
on the ground; i. e. the r e v e r s e control s y s t e m
of the propeller i s again energized permitting
unreversal t o take place. If the flag i s not
lifted when the throttle i s moved forward the
blades will remain in r e v e r s e pitch and the
amount of r e v e r s e thrust developed will depend
upon the amount of throttle applied.
Within a few days following this accident
U A L conducted a s e r i e s of flight tests to f u r t h e r
investigate, among other things, the effects of
a reversed outboard propeller upon the handling
characteristics of a DC-6 a t low airspeeds.
These t e s t s indicated, among other
things, that in the take-off configuration with
M E T 0 power o r higher on No. 1, No. 2 , and
No. 3 engines, the aircraft almost immediately
became uncontrollable when full power was
applied in r e v e r s e on No. 4 engine and the a i r -
craft speed was 100 knots o r less. In this t e s t
the roll was delayed f o r a short time by using
full opposite aileron. The violent yawing con-
tinued, however, with an attendant loss of a i r -
speed, and within a few seconds a violent roll
and pitch developed. The resulting a i r c r a f t
manoeuvre closely approximated the manoeuvre
which the a i r c r a f t made.
One of the most significant points devel-
oped during the t e s t s related to the posit~oning
of the throttle following an unintent~onaldis-
placement of the throttle into the r e v e r s e range.
The tests confirmed the fact that if the throttle
i s moved into Ihe r e v e r s e range during a take-
off run, moving the throttle back into the for-
ward thrust range after becoming airborne
will not bring the propeller out of r e v e r s e but
will only result in increased thrust power.
This follows since, a s described e a r l i e r , the
reversing circuity i s de-energized upon be-
coming airborne, and the propeller remains in
the r e v e r s e range, in which position it was
placed while on the ground. Unreversing can
only be accomplished under this condition by
depressing the feathering button or by raislng
the r e v e r s e warning flag and advancing the
throttle.
100 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
In the investigat~on, computations were
,,ldde to determine what the V1 and V2 speeds
would have been f o r the a i r c r a f t a t the time of
take-off.* This brought out that the V1 speed
was approximately 80 knots and the V2 speed
approximately 92 knots. The take-off distance,
a s measured, showed that the a i r c r a f t became
a i r b o r n e a t about V2. Witnesses s t a t e d that the
take-off appeared n o r m a l i n a l l r e s p e c t s .
UALfs instrument proficiency check pro-
c e d u r e s were studied by Board investigators,
and the sequence in which the check pilot usual-
ly introduced the various check i t e m s was a s -
certained f r o m persons f a m i l i a r with his check
technique. It was found that he consistently
gave a i r w o r k i t e m s , a radio range problem,
and an ILS approach and initial landing a t Mac-
Arthur, in that o r d e r , and conscientiously fol-
lowed UALts thorough check procedures. When
he was checking two captains, he would usually
give both of them the a i r w o r k and range prob-
l e m before the ILS approach was made. The
pilot who made the landing a t MacArthur would
then be told to make an instrument take-off
and advised that he would be given a simulated
f a i l u r e of a n outboard engine on take-off. After
this was accomplished they would change s e a t s
in the a i r and the other pilot would then be
checked on his ILS approach and landing, and
on his instrument take-off, with a simulated
engine failure.
Company instructions specify that the
simulated engine failure will be accomplished
by reducing power to z e r o thrust. This i s
about 1 200 r . p. m . , o r 300 r . p. m. m o r e than
iorward idle. In testimony interpreting flight
n ~ a n u a lir~structionson when the power reduc-
tlon i s to be initiated, IJAL1s director of flying
stated that the power reduction will be made in
the vicinity of and following V2. The manager
of flight operations f o r the New York a r e a , the
immediate superior of the check pilot aboard
the a i r c r a f t , further advised that the throttle
reduction i s s t a r t e d on the ground and z e r o
thrust position i s reached shortly a f t e r becom-
ing airborne. Climb should be made at V2. At
l e a s t t h r e e seconds a r e to be taken in retarding
the throttle steadily and positively; this i s t o
prevent snapping o r chopping the throttle back,
with attendant difficulty in maintaining control
of the a i r c r a f t . On a check flight shortly before
the accident, a CAA Aviation Safety Agent
noted that the check pilot took five o r s i x
* V1 - Critical engine failure speed, with adequate control to permit continuance of take-off.
VZ - Minimum take-off safety speed, p e r n t t t i n g
/
seconds to r e t a r d the throttle to z e r o t h r u s t
in a p s i t i v e and deliberate manner.
The company a l s o has instructions
that the check pilot will consider s e v e r a l
f a c t o r s , such a s wind conditions, location of
buildings on the a i r p o r t , and the proximity
of congested a r e a s n e a r the a i r p o r t , in selec-
tion of the outboard engine on which he will
simulate failure. In this c a s e , No. 4 engine
was the proper one f o r the simulated failure.
The UAL manager of flight operations
f o r the New York a r e a testified that the check
pilot would logically have given a n instrument
take-off and simulated engine failure a t this
point in the check.
Following acquisition of DC-7 equip-
ment and favorable operating experience with
the sequence gate latch (or Martin b a r ) on
those a i r c r a f t , UAL decided t o equip i t s DC-6
and DC-6B a i r c r a f t with the device. In prin-
ciple, i t consists of a b a r placed a c r o s s the
throttles a t the idle position. It may be mov-
ed out of the way by the pilot when he wishes
t o pull the throttles back into r e v e r s e ; when
in position, it i s impossible to pull the throt-
tles into r e v e r s e . O r d e r s were placed f o r the
Martin b a r k i t s s e v e r a l months p r i o r t o this
accident and the f i r s t DC-6 was modified about
a week before the accident occurred. UAL
expects to have i t s DC-6 and DC-6B a i r c r a f t
modified with the Martin b a r by F e b r u a r y
1956. A UAL engineer testified that although
the present propeller control s y s t e m h a s
functioned quite satisfactorily, the mechanical
lock feature of the Martin b a r (actuated by the
pilot) should make i t a m o r e reliable and s a f e r
device than the previous installation ( a s in
this a i r c r a f t ) , with i t s numerous switches,
r e l a y s , and automatic operation.
Reverse t h r u s t indicator lights were
not installed on the a Q c r a f t . At the t i m e of
the accident a p r o g r a m was in being to install
them on UAL DC-6 and DC-6B a i r c r a f t . The
light comes on a s warning to the pilot that a
propeller i s reversing when the propeller, in
the UAL installations, p a s s e s the z e r o degree
blade angle.
The flight experiments showed that a t
take-off configuration and airspeed, the a i r -
c r a f t will become uncontrollable with a n out-
board propeller in r e v e r s e pitch and i t s engine
operating a t full power. Control will be lost
s o quickly that t h e r e i s little, if anything, that
a specified s a t e of climb.
 ICAO Circular 50-AN/45 101

the pilot can do if it occurs a t low altitude. He things, plus the fact that examination of the
must recognize what i s occurring, analyze i t , propeller control s y s t e m produced nothing
and take action to unreverse in a very limited indicating malfunction, make it more probable
amount of time. It i s doubtful that unrevers- that the pilot unintentionally brought the throt-
ing could have been accomplished in this in- tle too f a r back rather than a malfunction having
stance before control was lost. Owing to the occurred.
time element, it i s a l s o questionable that pro-
peller reversing warning lights would have The Martin b a r , or sequence gate latch
been of any aid in this instance. kits were being delivered to UAL a t the time of
this accident, and installation was proceeding
The t e s t s brought out that i f the throttle a s fast a s deliveries could be made. UAL1s
of the reversed propeller i s a t either forward decision to install the Martin b a r was predicated
or r e v e r s e idle, the engine will s t a l l when the on i t s belief that the device was a simpler and
a i r c r a f t i s airborne. There was evidence that more positive means of reducing the possibility
the No. 4 engine was running a t impact. The of unwanted r e v e r s a l s . Recognizing these de-
t e s t s also showed that in o r d e r to approximate sirable features, and on the basis of service
a flight path s i m i l a r to that of the a i r c r a f t , experience, the CAA on 29 August 1955, issued
full r e v e r s e power was required on No. 4 en- Airworthiness Directive 55-18-2 which required
gine (with the propeller in reverse), and the that DC-6 and DC-6B a i r c r a f t (among o t b e r s )
other three engines developing M E T 0 power. be equipped with the sequence gate latch, o r
Further, it would be a natural reaction for the equivalent, by 1 January 1957.
pilot to move the throttle f r o m the r e v e r s e
range in an effort to unreverse. However, if It should be noted that the circumstances
the r e v e r s e warning flag were not lifted, ad- of this accident were entirely peculiar to pilot
ditional r e v e r s e power would continue to be proficiency testing and would not occur in
delivered. This evidence leads to the conclu- scheduled operation, for the reason that a
sion that the throttle was in some position throttle would not be retarded in scheduled
other than idle and an undetermined amount of operation to simulate engine failure. To do so
r e v e r s e thrust was being delivered. r e q u i r e s considerable rearward movement of
the throttle, and normal power reductions fall
The r e v e r s e pitch position of the No. 4 f a r short of this amount of retardation.
propeller could have been the result of (1) fail-
ure o r malfunction in the propeller control Probable Cause
system, o r (2) unintentional action by the check
pilot in retarding the throttle too f a r just before The probable cause of this accident was
becoming airborne. unintentional movement of No. 4 throttle into
the r e v e r s e range just before breaking ground,
Examination of all relays, switches and with the other three engines operating at high
other components of the electrical system of power output, which resulted in the a i r c r a f t
No. 4 propeller failed to disclose any evidence v e r y quickly becoming uncontrollable once a i r -
of operational failure o r malfunction. It i s borne.
reasonable to conclude, therefore, that pro-
peller r e v e r s a l did not occur a s a result of
electrical s y s t e m failure o r malfunction. F i r e Aspects (Excerpts f r o m NFPA
Special Aircraft Accident Bulletin,
Investigation showed s e v e r a l things Series 1955: No. 2)
which indicate an instrument take-off and sim-
ulation of engine failure. In accordance with
company requirements, No. 4 was the proper F i r e extinguishment progress was pain-
engine to select f o r the simulated failure; fully slow in this accident because
this was the logical point in the check to give
these two items; and the short delay a t the 1) the fuel tanks ruptured a t impact;
end of the runway coincided with the practice
of making a final check of all items before an 2) the flame spread was unimpeded and
instrument take-off. An instrument take-off "raked the fuselagel8 (with magnesium
would normally be followed by a simulated complicating the f i r e control efforts);
engine failure; had an instrument take-off not
been made, there might be some question that 3) f i r e equipment response was delayed
a simulated engine failure was given. These by t e r r a i n conditions.
102 ICAO Circular 5 0 - ~ ~ / 4 5
Response to the accident by f i r e apparatus
of the Airport (Sperry F i r e Department) was com-
menced immediately a s the control tower gave
the a l a r m promptly. The i i r s t unlts reached the
accident site in approximately 1-1/2 minutes; a
very severe f i r e existed a t this time. The site
was visible by flame and smoke but the land on
which the a i r c r a f t came to r e s t was marshy and
extremely muddy. Heavy brush covered the field
and was ignited in the immediate a r e a . A drain-
age ditch blocked the closest approach route.
The bogging down of the vehiclqs on ap-
proaching the accident site highlights one of the
worst problems in designing adequate "crash1'
equipment. There i s always the desire to hold
cost down to a minimum by buying a standard
chassis with conventional truck drive, g e a r s
and t i r e s . The performance recommendations
for these vehicles, however, require that very
special attention be given to acceleration, speed,
traction and flotation to a s s u r e that:
ICAO R e f : ~ ~ / 3 8 5
"the vehicle ... . ..
is suitable for c a r r y -
ing i t s full load a t relatively high r a t e s of
speed over a l l types of roads, t r a i l s , o p a
and rolling country under all reasonable
conditions of weather and t e r r a i n on the
movement a r e a of the a i r p o r t and in the
immediate vicinity thereof. N F P A No.
403 P a r a . 307 (b)
This problem is becoming more and more
serious a s vehicle weights a r e increasing and is
deserving of increased attention by a i r p o r t au-
thorities. Ditches which bar approaches to po-
tential accident s i t e s should be bridged o r filled
in advance of the emergency and t r i a l s conducted
with vehicles to a s s u r e their cross-country a-
bility on a i r p o r t t e r r a i n and on surrounding prop-
e r t i e s , especially along take-off and approach
paths.
Figure I 2 Notional Fire Protection nitassciatien Photo

United A i r Lines DC-6 which ccashsd wMYe on a pilot qualification check ZJigM at MzfcArtbus Field, Islip, N e w Vosk - C"
c1
bJ
4 April lW5* intense f i r e consumed a l a r g e pirtian of the wreckage in spite of prompt arrival. of Eire f i ~ h f i n gequipment,
United Ax*. Liners: DC-6 -. Xsirp, N,Y, -. 4 A p r i l 2955, *V"beoff-runway l a n d on w c n h the aircraR came
to rest w a x rrrassSiy and e~rrrrmelymuddy. A drdxxage &tck blacked the closest approach route,
 ICAO C i r c u l a r 5 0 - ~ N / 4 5 105

No. 19

Eagle Aviation Company, Dakota DC-3 a i r c r a f t , Lebanon, G-AMYB,

groundlooped on la?ding run a t Beirut International Aerodrome. 8 April 1955.
Aircraft Accident Report No. 15 released by Air Safety and Accident Inquiry Department
Ministry of Public Works, Directorate of Civil Aviation, Lebanon.

Circumstances of the e n t i r e cabin, and a s m a l l food locker of

The a i r c r a f t had been c h a r t e r e d by a tour-
ist agency f o r a group of Americans wishing to
visit the major cities of the Middle E a s t , The
flight departed F r a n k f o r t on 7 April 1955 a t 2230
GMT en route to Beirut with numerous interme-
diate stops carrying 4 c r e w and 28 passengers.
At 1720 GMT on 8 April the a i r c r a f t reported
being on final approach over Beirut. On landing
a t 1724 GMT in a strong crosswind, the a i r c r a f t
bounced twice, groundlooped and came to r e s t
920 m e t r e s f r o m the runway threshold facing
into the wind. While skidding, the main door of
the cabin came a j a r and the s t e w a r d e s s , not
seated with h e r safety belt fastened, was thrown
f r o m the a i r c r a f t to a point 12 m e t r e s f r o m i t s
tail and s e r i o u s l y injured.
-
Investigation and Evidence
Meteorological conditions reported by the
control tower a t the time of the accident w e r e a s
follows :
surface wind: direction 270 "
force 30 knots
pressure: QNH 1015.0 mb; 29.97 l1
the type used on Vikings was found overturned.
The a r r a n g e m e n t s of such c a s e s a s w e r e not
thrown forward showed that they must a l l have
been behind the l a s t row of s e a t s on the s t a r -
b o a r d side. The c a s e s w e r e stacked higher
than the top of the seat-back. One of the wooden
c a s e s and one of the c a r t o n s were a few centi-
m e t r e s f r o m the cabin door, level with the
handle of the lower lock.
The door locks by means of two independ-
ent locks operated by two handles positioned
one above the other. The upper handle a c t s
upon an ordinary horizontal latch, the lower
one upon a rod locking the door vertically.
, Because the c u s t o m s officers closed the door
and affixed s e a l s , i t was impossible t o d e t e r -
mine the position of the handles a t the t i m e of
the accident. However, examination of the
locks revealed that the upper inside handle
operating the horizontal latch often turned with-
out engaging the lock mechanism, and f u r t h e r -
m o r e that the latch was covered with r u s t . The
corresponding outside handle worked perfectly
on e v e r y operation. The upholstery of the door
exhibited the t r a c e of the impact of a pointed
instrument. However, it was impossible to
determine either the cause o r the date thereof.

QFE 101 1. r, ~ n b 29.87

; " The statements of the witnesses brought
out the following points :
visibility: 5 miles
1) the a i r c r a f t had been shaken before touch-
no gusts down ;

The investigators attempted f i r s t of a l l to 2) the landing a t Beirut left much to b e

determine the t r a c k s of the a i r c r a f t and the f i r s t
well-defined point of cor,tact was found opposite
m a r k e r 34G i.e. 660 m e t r e s f r o m the runway
threshold, and 14 m e t r e s to the left of the runway
centre llne. F o r a distance of 120 m e t r e s this
t r a c k remained parallel to t h c c e n t r e line, then,
over a distance of 50 m e t r e s it bore to the right
and a t this point the a i r c r a f t definitely skidded to
the right and stopped 90 m e t r e s f a r t h e r on i.e.
260 m e t r e s f r o m the f i r s t observed point of con-
tact.
Inspection of the cabin showed a number of
c a s e s and cartons of beverages littering the floor
d e s i r e d no doubt due to bad weather;
3) the door of the a i r c r a f t was open when
the s t e w a r d e s s was thrown out and s h e
did not hit the door;
4) the stewardess usually s a t down a t the
time of take-offs and landings, however,
on the day of the accident no one r e m e m -
b e r e d seeing her do s o ;
5) no witness was able to determine the
exact point on the runway a t which the
f i r s t contact occurred. One passenger
106 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
declared that the rlght wing was s o high
that it shut off h e r view of the ground
f r o m h e r seat;
no passenger noticed any i n c r e a s e in the
6)
power of the engines which would have
been apparent f r o m a louder engine noise;
7) the o r d e r to fasten safety belts had been
given long before the landing;
8) the captain of another a i r c r a f t which had
landed a few minutes before the subject
a i r c r a f t testified that the l a t t e r made a
low landing on the runway and appeared
to b e holding a perfectly straight c o u r s e
when the right wing lifted to a consider-
able angle and he f e l t that the a i r c r a f t
might overturn. Then i t skidded to the
right and stopped.
Several theories follow a s to the cause of
the accident, however, those concerning the Another aggravating circumstance was the
opening of the door cannot be proven particular- presence in the cabin of a food locker and c a s e s ,
ly in view of the action taken by the customs completely unsecured, which in falling a l s o con-
agents who, by closing the door, made i t im- tributed to the accident.
possible to determine the position of the handles
operating the locking mechanism.
At the time of take-off, the stewardess
always checks that the door i s safely locked by
trying the handles. In s o doing she might have
opened the top lock, since i t was found thus
. ..
and s i n r e the top inside lock o p e r a t e s only one
way to unlock. The door, therefore, lock-
ed only by the v e r t i c a l rod operated by the
lower handle.
When the a i r c r a f t went into a sudden skid,
one of the c a s e s , in falling, probably hit the
lower handle, thus unlocking the door. A 5
centimetre movement of the handle was suffi-
cient to produce this result. The stewardess
must a t this time have been standing behind
the r e a r m o s t right-hand seat. The s m a l l food
locker, in falling, must have hit her and knock-
ed her over. If she was facing the door a t the
time and holding onto the top b a r of the s e a t
with h e r right hand, her fall would have assurn-
ed a spinning motion which would explain why
one of the passengers saw h e r fall backwards.
The finding of the s t e w a r d e s s 1 right shoe in the
s m a l l food locker appears to f i t in with this
theory
The pilot had put the flaps full down for
a landing in a 60 " crosswind with a force of
30 knots. The instructions f o r a landing under
such conditions specify: approach with power,
flaps up o r a t m o s t 1/4 down. The effect of the
wind on flaps in the full down position i s t o
f o r c e the a i r c r a f t to t u r n into the wind. NO
action taken by the pilot could have c o r r e c t e d
this.
Such a mistake s e e m s illogical when i t i s
noted that the pilot had logged over 5 300 hours
a s pilot-in-command. However, the crew had
been flying f o r nearly 21 consecutive hours
( f r o m 2030 G M T on 7 April 1955 to 1724 GMT on
8 April 1955) without any r e s t , landing having
been made only f o r technical r e a s o n s . A second
pilot-in-command had left the flight a t Nicosia.
The pilot stated that he had had two r e s t periods
of t h r e e and a half hours each. This would
reduce his actual duty time to 14 hours. However,
these periods cannot be considered a s r e s t a s
the pllot had no opportunity to r e s t properly.
Therefore, t h e r e i s a possibility of fatigue having
influenced his judgment.
Probable Cause
The pilot made a full flap landing in a
strong crosswind causing the a i r c r a f t to ground-
loop, whereupon the main door of the cabin open-
ed and the s t e w a r d e s s was thrown f r o m the a i r -
craft.
Contributing f a c t o r s were:
1) possibility of fatigue effecting pilot's judg-
ment;
2) presence of unsecured c a s e s in the cabin
(loading fault) ;
3) the s t a t e of the horizontal lock (mechanical
fault);
4) violation of r u l e s by the stewardess In
that she was not seated with safety belt
fastened a t time of landing.
Suggestions
1) When t h e r e i s a strong qrosswind the f i r e
truck and ambulance should be n e a r the f i r s t
intersection of the runway in use. In this instance
there was a five minute tlme lapse between the
time of the accident and the a r r i v a l of the ambu-
lance. This delay was due to the fact that the
tower waited for the pilot's request before send-
ing help.
 ICAO Circular 50-AN/45
2) Ordersshouldbegiventoallofficial
agencies a t the aerodrome and in the various
ministries stipulating that no a i r c r a f t involved
in an accident should be touched before a r r i v a l
of the investigators. The a i r c r a f t should be
placed under guard and no evidence disturbed
unless absolutely necessary for the extraction
of passengers.
ICAO Ref: ~ ~ / 3 6 4
107
3) A technical memorandum should be
circulated reminding all crew members of the
absolute necessity of being seated with belts
fastened on landing and a t take-off.
4) A control followed by checks must be made
and measures taken if any c a s e ia revealed of non-
observance of hours d d u t y f o r crew members.
108 ICAO Circular 5 0 - ~ ~ / 4 5

No. 20

Air India International Corporation, Bombay, Lockheed Constellation 749-A,

VT-DEP, "Kashmir Princessll, ditched following mid-air explosion in South
China Sea, off G r e a t Natuna Islands on 11 April 1955. Report by Ministry of
Transport and Communications, Republic of Indonesia, released 25 May 1955.

Circumstances together with rectification work for the defects

The a i r c r a f t took off f r o m Hong Kong for
Djakarta a t 0425 hours Greenwich Mean Time
carrying 8 crew members and 11 passengers.
The flight was uneventful until approximately
five hours after take-off when a muffled explo-
sion was heard in the a i r c r a f t , then cruising at
18 000 feet over the sea. Smoke started enter-
ing the cabin through the cold a i r ducts almost
immediately and a localised f i r e was detected
soon after on the starboard wing behind No. 3
engine nacelle. A rapid descent was commenced
for dltching the a i r c r a f t and d i s t r e s s signals
broadcast. In spite of f i r e fighting action, dur-
ing which No. 3 engine was feathered, the f i r e
spread very rapidly and caused hydraulic failure
followed by electrical failure. During the final
stages of the descent, executed under extremely
difficult circumstances, dense smoke entered
the cockpit reducing the visibility to almost nil.
The a i r c r a f t impacted the water with the s t a r -
board wing tip, and the nose submerged almost
instantaneously. Only three crew m e m b e r s
survived the accident. The a i r c r a f t was de-
stroyed.
Investigation and Evidence
The aircraft had crashed into the s e a 235
miles northwest of Kuching. The wreckagewas
located by Indonesian fishermen on 12 April
1955 a t an average depth of 35 feet of clear
water, but i t could not be seen from the surface.
Salvage operations, which were hampered due
to the presence of sharks, commenced on 25
April and lasted for ten days. The wreckage
indicated that the a i r c r a f t had suffered consid-
erable damage on impact with the sea, in addi-
tion t o f i r e damage. Salt water corrosion was
m o s t noticeable on magnesium alloy engine
parts; other parts were comparatively free.
The a i r c r a f t had been inspected by li-
censed a i r c r a f t maintenance engineers a t
Bombay on 8 April 1955 and had then taken off
on the evening of 8 April to operate a scheduled
flight to Singapore, returning to Bombay on 10
April after an uneventful flight. On a r r i v a l at
Bombay, a terminal check was c a r r i e d out,
reported during the previous flight. The a i r -
craft then taxied out to the runway to operate a
scheduled flight to Hong Kong via Calcutta and
Bangkok, taking off on the afternoon of 10 April.
At Bangkok a fresh crew took over the aircraft.
The composition of the crew was then the same
a s that of the subsequent Hong Kong-Djakarta
flight. The a i r c r a f t was a t Hong Kong for 80
minutes during whlch the crew received their
briefing, a transit check was c a r r i e d out under
the supervision of the a i r craft maintenance
engineer and the a i r c r a f t was loaded and r e -
fuelled. At 0425 hours Greenwich Mean Time
the a i r c r a f t took off f r o m Hong Kong for Djakarta
and was routed to overfly the Natuna Islands for
navigational check purposes,
After take-off, routine messages were
exchanged by the a i r c r a f t with ground stations.
The explosion occurred a t approximately 0923
hours. Once a rapid descent and depressuriza-
tion were commenced a bank of C02 bottles was
discharged into the r e a r baggage compartment
in accordance with the f i r e drill. By this time
the navigator had noticed a f i r e on the s t a r -
board wing behind No. 3 engine nacelle which
was spreading very rapidly and this was report-
ed to the captain. The generators were switched
off a s a precaution against electrical fire but
again switched on l a t e r , At this time the crew
prepared for ditching. The fire spread rapidly
and was approaching the fuselage. The a i r -
craft maintenance engineer estimated that the
wlng would not hold on f o r long a s metal was
melting. The f i r e warning in No. 2/3 Zone of
No. 3 engine then came on. No. 3 engine which
was functioning normally was feathered and the
remaining bank of C O ~ b o t t l e swas discharged
in No. 2/3 zone. The starboard heater f i r e
warning then came on but the extinguishers had
been exhausted. A left hand turn was executed
in an attempt to ditch near land. The navigator
had in the meantime located the position of the
a i r c r a f t and passed it to the co-pilot, who had to
help the captain with the controls a s the a i r c r a f t
was getting uncontrollable due to the starboard
wlng dlopping. At this stage hydraulic failure
w a s reported, and the auxiliary boosters were
switched on. Smoke then entered the crew
 ICAO Circular 5 0 - ~ N / 4 5
compartment, The a i r c r a f t maintenance
engineer opened two port emergency exits in
the cabin over the wing and one in the crew
compartment. At this stage very thick black
smoke entered the crew compartment which
obscured forward visibility just p r i o r to ditch-
ing. The 00-pilot opened the sliding window on
his side and had to peer a t the instrument panel
to check the airspeed indicator reading which
was 140 knots when he l a s t observed it.
In spite of all efforts to level off the a i r -
craft for ditching, it continued in a shallow
right hand turn and hit the water with the s t a r -
board wing. Flaps could not be used because
of hydraulic failure.
I t i s clear that the explosion was followed
by a combination of circumstances which em-
braced practically all emergencies that could
have faced the crew.- a serious f i r e that threat-
ened to burn off the wing any minute, hydraulic
failure, electrical failure, partial loss of con-
trol and dense smoke in the cockpit which re-
stricted the visibility to almost nil during the
most critical stages of the descent.
' a i r c r a f t hit the water, dense black smoke filled
Fortunately the right wing which included
the starboard wheel well was recovered. Posi-
tive confirmation i s available of an explosion
having taken place in this a r e a .
In addition to the physical evidence of
bulging skin and bent members, there was also
deep pitting by shrapnel in the skin surround-
ing the explosion a r e a , and on the 24 ST s t r u t s
and steel tubes which were facing the explosion
charge. Glancing dents have also been deeply
defined in those s t r u t faces which were parallel
to the flight of shrapnel. The fuel tank wall
was punctured inwards.
Finally p a r t s of a twisted, burnt and cor-
roded clockwork mechanism, which had no
relation to any equipment of the aircraft, was
found trapped in the very s a m e a r e a where an
explosion took place.
The explosion caused by this device r e -
sulted in puncturing of the fuel tank, and f i r e ,
which developed intensely a s i t was fed by large
quantities of high octane fuel. Heat f r o m this
fire travelled forward to No. 3 zone of No. 3
power plant, causing a fire warning f r o m this
zone. The discharge of C02 in this a r e a caused
ICAO Ref: ~ ~ / 3 9 7
109
the warning to go off. This f i r e a l s o burnt
through the r e a r beam web, which had also
opened up due to the explosion. Once the flames
had spread to the trailing edge a r e a behind the
beam, they s t a r t e d consuming the cabin a i r
ducting, cables and the fuel and hydraulic lines.
This explains the entry of s t r e a k s of
smoke noticed by the a i r c r a f t maintenance engi-
neer soon after the explosion, and the hydraulic
failure experienced a t a later stage. This hy-
draulic failure compelled the crew to switch on
the auxiliary boosters for the rudder and eleva-
tor. The heavy drain of electrical energy re-
quired for the operation of the boosters, com-
bined with the fact that the generators had also
to be switched off at,one stage a s a precaution-
a r y measure against electrical fire, would
undoubtedly exhaust the batteries. I t s e e m s
most probable, however, that the complete
electrical system went 'dead' a s a result of the
f i r e , and this explains why the co-pilot was una-
ble to send out the position r e p o r t during the
final stages of the descent.
The crew a l s o stated that just before the
the entire cabin and cockpit. It i s estimated
that i t took a t least 5 to 6 minutes for the a i r -
craft to descend f r o m 18 000 feet. During this
period the flames had spread to the right side
of the fuselage. The wreckage showed positive
evidence of this a r e a having burnt off in the air.
The dense smoke which entered the a i r c r a f t
was undoubtedly caused by the f i r e having en-
tered the cabin after burning through the side of
the fuselage.
The aforementioned facts combined togeth-
e r provide irrefutable evidence of an infernal
machine having been placed by some party un-
known in the starboard wheel well a r e a . presum-
ably to destroy the aircraft. The task of this
person was rendered e a s i e r by the fact that ac-
c e s s to this a r e a i s extremely easy through the
openings in the bottom skin of the wheel well,
when the a i r c r a f t i s on the ground.
Probable Cause
The cause of this accident was an explo-
sion of a timed infernal machine placed in the
starboard 'wheel well of the aircraft. This ex-
plosion resulted in the puncturing of No. 3 fuel
tank and an uncontrollable fire.
 110 ICAO Circular 5 0 - ~ N / 4 5
No. 21
Christian and Missionary Alliance, Short Sealand JZ-PTA, crashed on mountain
in highlands of Netherlands New Guinea on 28 April 1955. Report released by
Director of Civil Aviation, Netherlands New Guinea.
Circumstances
The amphibian a i r c r a f t departed Sentani
aerodrome near Hollandia on a VFR flight plan
for the Baliem River a t 0840 hours (local time)
on a transport flight carrying a load of furniture,
foodstuffs and aluminum sheets. At 0922 the
Biak a r e a control centre and Sentani aeronautic-
a l radio station both received a r e p o r t f r o m the
a i r c r a f t that i t was over the ldenburg River,
course 220 degrees, VFR a t 9 000 feet inslight
rain, operation normal. When the next position
r e p o r t over the Baliem became overdue, the
Sentani aeronautical radio station and the Biak
a r e a control centre attempted to contact the a i r -
craft, but to no avail. The a i r c r a f t was found
after one month of extensive searching, crashed
on a 10 335 foot high mountain. The sole occu-
pant, the pilot, did not survive the crash.
Investieation and Evidence
P r i o r to departure a Visual Flight Rules
flight plan was filed with Sentani a i r traffic con-
t r o l station indicating a flight to be flown clear
of clouds and with a visibility of a t l e a s t one
mile. There was sufficient fuel on board for
four hours. The flying time to the Baliem and
f r o m there back to Sentani was estimated to be
two hours and thirty five minutes. The gross
weight of the a i r c r a f t a t the time of take-off was
within the allowable gross weight of 9 600 lbs.
and the load was properly distributed.
After departing Sentani the flight progress-
ed in a routine manner and the following posi-
tion r e p o r t s were received at the radio commu-
nications stations a t Sentani and Biak:
2317 Z 4 000 ft. climbing 8 000,
course 225O VFR.
2341 Z 60 miles out, course 2250,
9 000 ft. operation normal,
slight rain.
2412 Z over Idenburg River, course
220° VFR. 9 000 ft. operation
normal, slight ram.
This was the last radio contact with the
flight.
On the morning of 28 April the weather
was a s follows: - the intertropical front was sit-
uated along the north coast of New Guinea. It
was rather active and locally even very active.
Overcast a t 10 000 ft. with r a i n over the low-
lands, mountain tops well in clouds with valleys
partly closed with stratus, generally westerly
winds of approximately 20 knots. Air reports
f r o m scheduled flights into and out of Sentani
aerodrome gave poor weather conditions in the
Hollandia a r e a .
At take-off time the Sentani weather con-
ditions were: - no wlnd; visibility 2 km; moder-
ate continuous rain.
p a s t weather - rain, cloud 4/8 s t r a t u s
1 200 f t . 8/8 alto s t r a t u s 10 000 ft.
At 0915 (local time) an improvement
message was issued.
-
no wind, visibility 5 krn. moderate
continuous rain.
p a s t weather -
rain, clouds 3/8 s t r a t u s
1 800 ft. 8/8 alto stratus 10 000 ft.
At 0930 (local time) the Sentani synoptic
r e p o r t indicated:
- no wind, visibility 3 km. moderate
continuous rain.
a s t weather - rain, 2/8 stratus 1 800 ft.
*-stratus 10 000 ft.
Since no a r r i v a l report f r o m the a i r c r a f t
was received over the Baliem River a n a l e r t w a s
declared by the Biak a r e a control centre a t 1045
hours (local time).
Search and Rescue flights were executed
by PBY a i r c r a f t of the Royal Netherlands Naval
Air Services, a Piper P a c e r of the Unevangelized
Fields Misslon and a de Havilland Beaver of New
Guinea Airline llKroonduifl'.l Extensive search-
ing was done over jungle covered mountainous
t e r r a i n for more than two weeks in successlon.
When reports came in that a n a i r c r a f t had been
seen to crash into Sentani Lake adjacent to
Sentani aerodrome, an extensive diving opera-
tion was carried out, but not the slightest traces
of an a l r c r a f t could be found.
 ICAO Circular 50-AN/45
On 28 May an Australian Avro Anson was
chartered in o r d e r to c a r r y out a final s e a r c h
flight. This a i r c r a f t spotted JZ-PTA a t an al-
titude of approximately 10 000 ft, crashed on a
mountain slope. There were no t r a c e s of f i r e ,
but from pictures taken from the searching a i r -
craft it was learned that the a i r c r a f t had com-
pletely disintegrated and survival of the c r a s h
by the only occupant - the pilot - was highly
unlikely.
In viewof the inaccessibility of the t e r r a i n
where the a i r c r a f t crashed i t was not possible
{CAO R e f : ~ ~ / 3 7 8
111
to send out a ground party to the scene of the
crash.
Probable Cause
The investigating authority reached the
conclusion that the probable cause of the acci-
dent was the fact that the pilot was caught in
adverse weather conditions during his attempt
to reach better visibility conditions by climb-
ing to a higher flight level and during this ma-
noeuvre collided with a mountain,
 F r p u r e 14
A r r o w tadicrttea, Xoeat~anof wreckage of Short Sealand, J Z - P T A ,
which sraahed in highlands of N e a c r l m d s New Guinea on 28 A p r i l 1955,

Prgure IS
la v w w of the rnaccesslhtlrty of the lesraln where JZ-P'TA c r a s h e d
11 wae n u t possrblc to send a grourrd party to the scene of the accrdenl,
 ICAO Circular 5 0 - ~ ~ / 4 5 - 113

No. 2 2

Trans-Canada Airlines, Inc., Vlckers Vlscount 724 aircraft, was damaged on

landlng at Winnipeg. Manitoba, on 16 May 1955. Canadian Department of Transport
Report No. 55-21.

Circumstances off, but on landlng the m i c r o switch would com-

The a i r c r a f t took off from Winnipeg at
1233 hours Central Standard Time on a local
training f l ~ g h tcarrying three pilots. The take-
off was a normal three engine take-off and after
the a i r c r a f t was airborne the pilot-in-command
pressed the undercarriage selector switch but
the under carriage failed to retract. "Down"
and "upI1 were again selected but without result.
'The hydraulic selector valve was then inspected
visually and found to be in the Itdownttposition
indicating that the undercarriage was down.
The visual indicators on the wlng and the nose
wheel indicator indicated that both the under-
carriage and nose wheel were down. The under-
carriage lights remained green throughout the
fllght and the horn did not sound. On touching
down, the undercarriage retracted and a s the
a i r c r a f t was sinking the horn sounded twice.
The a i r c r a f t was substantially damaged.
plete the circuit to the actuator when the nose
wheel touched the ground thereby positioning
the valve in the Itupfto r "down" position, de-
pending upon the position selected on the under-
carriage selector switch. Thus, if the under-
carriage selector switch had been selected "up"
the undercarriage would r e t r a c t . Similarly,
expert testimony was given to the effect that if
the undercarriage selector switch had been se-
lected "downtt it would not be possible for the
undercarriage to r e t r a c t unless there had been
another failure in the system.
The Trans-Canada Airlines Airplane
Operating Manual for Vickers Viscount 724 Air-
craft contains the following note:
"If landlng gear fails to r e t r a c t , rock nose
wheel steering to ensure centralising."
This instruction was not c a r r i e d out.

Investigation and Evidence Probable Cause

No evidence was found of malfunctioning The undercarriage selector switch was

of the englnes or controls but considerable left in the "up" posltion due to the failure of the
wear was found on the cam which operated the undercarriage to r e t r a c t after take-off. This
nose-centre~ng micro switch. This could cause resulted in the retraction of the undercarriage
f a ~ l u r eof the micro switch to operate on take- on landing.

I C A O Ref: ~ ~ / 3 9 3
114 ICAO C i r c u l a r 5 0 - ~ N / 4 5
No. 23
Douglas C-47, LV-ACQ, c r a s h e d a t Rfo Chico Aerodrome,
Santa C r u z T e r r i t o r y , Argentina, on 20 May 1955. Argentine Accident
Investigation Report No. 494, r e l e a s e d 17 November 1955.
Circumstances
The a i r c r a f t , a c a r g o plane, was
attempting a night take-off on the l a s t leg of
a c i r c u i t begun two days e a r l i e r in E z e i z a ,
with stops a t a l l a e r o d r o m e s on the Atlantic
seaboard. After a run of about 600 m e t r e s .
i t lifted in a gentle c u r v e to the left but hit
the ground again off the runway, skidding to
the right, The impact broke the left landing
g e a r s t r u t and the a i r c r a f t c a m e to r e s t a f t e r
travelling a s h o r t distance. F i r e b r o k e out
in the left engine nacelle and could not be put
out because of the lack of adequate f i r e fight-
ing equipment a t the a e r o d r o m e . No i n j u r i e s
w e r e sustained by the four c r e w m e m b e r s and
one p a s s e n g e r on board a t the t i m e of the
accident (approximately 0820 h o u r s ) .
Investigation and Evidence
Weather conditions a s shown in the
o f f i c ~ d lr e p o r t w e r e a s follows:
Sky with 6/8 alto-cumulus,
p r e s s u r e a t runway level
1 000. 8mbs. , visibility 40 kilo-
m e t r e s , t e m p e r a t u r e 3OC,
dewpoint 2OC, wind f r o m 70°
a t 16 knots.
The a i r c r a f t was operating with a weight
of 10 268 kg, 1 332 kg below the company's
maximum authorized take-off weight f o r this
a e r o d r o m e . The load was p r o p e r l y distrib-
uted according to the specifications of the
c o n t r o l l e r and the dispatcher. The runway
i n use was Runway 0 3 , which i s constructed
of compacted e a r t h , with a slightly uneven
s u r f a c e ; i t had been p r o p e r l y m a r k e d with
kerosene f l a r e s .
The routine pre-take-off engine and
equipment checks w e r e m a d e according to
company regulations; they indicated n o r m a l
operation, except f o r a slight o v e r s p e e d of
the left engine, which had been noted previous-
ly. Take-off was then s t a r t e d on c l e a r a n c e
f r o m the control tower, which i s situated a t
one of the four a e r o d r o m e s in the zone, and
f r o m which the operation was not visible.
The pilot-in-command, a t the c o n t r o l s , began
the manoeuvre f r o m the i n t e r s e c t i o n of the two
runways, leaving unused about 100 m e t r e s of
the runway in use; this was quite in o r d e r i n
view of the total length of the runway, t h e light
load of the a i r c r a f t and the f a c t that the unused
portion was a r e c e n t extension a s yet incomplete-
ly s u r f a c e d . He noticed a tendency of the a i r -
c r a f t to v e e r to the left soon a f t e r a c c e l e r a t i n g
the engines to take-off power, i. e . 48 inches
intake pressure. Becoming a i r b o r n e a t too low
a speed because of a s u r f a c e bump, he found
t h a t t h e swing to the left i n c r e a s e d to a point a t
which i t could not be a r r e s t e d with the rudder
n o r with the t r i m m i n g tab.
Once a i r b o r n e , the a i r c r a f t left the run-
way obliquely, inclining s l ~ g h t l yto the left.
When the pilot attempted to land within the l i m i t s
of the a e r o d r o m e by reducing power in the right
engine, the a i r c r a f t hit the ground with a violent
l a t e r a l skid which cdused the left s t r u t of the
landing g e a r t o b r e a k , the left engine w a s t o r n
f r o m i t s mount, and f i r e broke out. The a i r c r a f t
t r a v e l l e d 9 6 m e t r e s f r o m the f i r s t point of i m p a c t
t i l l i t c a m e to r e s t a t a n angle of about 1200 left
of i t s o r i g i n a l heading.
The investigation revealed the following
factors:
1 ) The weather w a s fine; wind speed and
direction e s t i m a t e d by w i t n e s s e s a s
n o r t h t o n o r t h - e a s t f r o m 7 t o 28 km/h
differ f r o m the official r e p o r t , which
gives north-east at 40 km/h. In nelther
c a s e , however, could the wind have
anything to do with the tendency of the
a i r c r a f t to swing sideways.
2) The safety lock of the m a i n landing
g e a r s t r u t s was on and the tail wheel
was in longitudinal alignment and locked
in n o r m a l position.
I
3) The rudder tab w a s found in the posi-
tion in which the pilot stated he had
placed it.
4) Both p r o p e l l e r s w e r e t o r n f r o m the en-
gines and w e r e found s o m e distance away.
 ICAO Circular 5 0 - ~ ~ / 4 5
a ) No. 2 propeller broke f r e e , and
it i s considered, taking into
account the twisting of the blades,
that i t hit the ground, p.artly
breaking the front housing, and
was then shaken off by vibration.
The blades of this propeller were
within the normal pitch positions.
b) The blades of No. 1 propeller
were on feathered pitch, only one
being twisted backwards, proba-
bly f r o m having supported the
weight of the a i r c r a f t , Two of
the blades bore the m a r k s of twist-
ing starting a t the propeller hub,
probably due to r e a r w a r d p r e s s u r e ;
i t was i n f e r r e d that t h i s o c c u r r e d
when they hit the ground while
feathered.
T e s t s c a r r i e d out on the
governor and on the propeller it-
self showed no operating defects,
except f o r some looseness of the
speed stop lug of the governor,
which would have resulted in a
speed g r e a t e r than normal, and
this factor, in operation, would
have facilitated the c o r r e c t i o n
attempted by the pilot.
TO A n R e f : XIG/ACC/REP/GEN/NO. 7
( A r g . Bulletin No. 4, p. 4 6 . )
115
5) A number of p a r f s of No. 1 engine
were fused together by the f i r e , so
that i t was impossible to check i t s
feed, carburation and igniting
s y s t e m s ; however, the inspection
revealed nothing abnormal in the
remaining elements.
6) The e l e c t r i c c i r c u i t controlling the
feathered pitch of the p r o p e l l e r s
could not be checked, a s i t was com-
pletely destroyed in the f i r e ,
Analysis focuses attention on the l e f t
propeller blades, which were folded back i n
a manner suggesting that they were feathered
when they touched the ground. F o r undeter-
mined reasons, the propeller a p p e a r s to have
been feathered during the take-off manoeuvre;
this would explain the tendency of the a i r c r a f t
to pull to the left because of a s y m m e t r i c a l
traction. In accidentally becoming airborne
too soon, i t did not have sufficient lift to be
controlled, hence the consequences s e t out
above.
Probable Cause
The probable cause of this accident was
the fall cf the a i r c r a f t when the pilot decided
to discontinue a take-off which he considered
abnormal and which i s attributed to the fact
that the propeller was probably feathered, f o r
undetermined reasons.
116 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
No, 24
Associated Airways Limited, Avro York a i r c r a f t , CF-HMY,
c r a s h e d on take-off f r o m Edmonton Airport, Alberta. Canada on 26 May 1955.
Report by Board of Inquiry appointed by Minister of T r a n s p o r t .
Circumstances
The a i r c r a f t was taking off a t 1427 h o u r s
f r o m the north-south runway (33-15) of Edrnon-
ton Municipal Airport when i t hit a n obstacle
in line with and off the end of runway 33-15
causing i t to c r a s h a t the north (15) end of the
runway and b u r s t into flames. Both occupants.
the pilot and the co-pilot, w e r e killed and the
a i r c r a f t was completely destroyed.
Investigation and Evidence
The following f a c t s were brought out
in the investigation:
1) The a i r c r a f t was duly licensed by the
Department of T r a n s p o r t a s w e r e the
pilots.
2) Edmonton a i r p o r t is 2 185 feet above
mean s e a level.
3) The runway used i s 5 700 feet in
length with no approved overrun.
4) The a i r c r a f t was loaded to 67 6831bs.
g r o s s , the maximum permitted by
the Certificate of Airworthiness be-
ing 68 000 lbs.
At the time of take-off the temperature
was 69O Fahrenheit, the wind was light and
variable, averaging l e s s than 7 m.p.h.
The P e r f o r m a n c e Schedule f o r t h i s type
of a i r c r a f t disclosed that under the prevailing
loading and weather conditions, the a i r c r a f t ,
to take-off in safety, would have required a
runway 7 100 feet in length. Under the pre-
vailing conditions, the a i r c r a f t , operating
normally and under full throttle could not,
and in fact did not, effect a safe take-off.
ICAO Ref: AR/414
A b r e a c h of p a r a g r a p h 813, A i r Regula-
tions, o c c u r r e d in that the captain neglected
"the precaution that may be r e q u i r e d by the
ordinary practice of the a i r , o r by the special
c i r c u m s t a n c e s of the caset1.
The following additional i t e m s of negli-
gence w e r e found:
a) the Department of T r a n s p o r t issued
a licence to the captain of the a i r -
c r a f t without e ~ a ~ i n a t i oeithern a s to
his flying ability o r a s to h i s knowledge
of the flying c h a r a c t e r i s t i c s and p e r -
formance limitations of York a i r c r a f t
under the conditions which prevail as
to weather and a i r p o r t altitudes in
Canada;
the Department of T r a n s p o r t did not
a s s u r e itself before issuing a Certif-
icate of A i r w o r t h i n e s s for the York
a i r c r a f t , that the owners of the a i r -
c r a f t had in their possession the
n e c e s s a r y P e r f o r m a n c e Schedule;
c ) the owners of the a i r c r a f t did not pro-
vide the pilots with the P e r f o r m a n c e
Schedule f o r the a i r c r a f t s o that the
captain had no a c c u r a t e means of
knowing what load he could safely
c a r r y under the prevailing circum-
stances;
d) the owners of the a i r c r a f t had not
tested the pilots a s t o their ability
and a s to their knowledge of the
limitations of the York a i r c r a f t .
Probable Cause
The p r i m a r y cause of the accident was
the attempt of the pilot to take-off under the
prevailing unfavourable conditions. As a
r e s u l t , the a i r c r a f t hit a n obstacle in line with
and off the end of the runway.
 ICAO C i r c u l a r 5 0 - ~ N / 4 5
No. 25
Northeast Airlines. Inc.. Douglas DC-3. overshot the runwav on landing
Circumstances
The flight took off f r o m L a Guardia Air-
p o r t , New York, a t 1612 E a s t e r n Standard Time
on a Visual Flight Rules flight plan e n route to
Lebanon A i r p o r t , New Hampshire. Due to
t h u n d e r s t o r m s and poor radio reception Keene,
New Hampshire, a scheduled stop, was o v e r -
flown, After finding a 5 000 foot ceiling a t
Lebanon the flight cancelled i t s Instrument
Flight Rules c l e a r a n c e and proceeded VFR f o r
landing a t Lebanon. During the landing run
the a i r c r a f t rolled off the end of the runway,
s t r u c k a ditch and c a m e to r e s t on the under-
side of i t s fuselage 57 feet f r o m the end of the
runway. T h e r e were no i n j u r i e s among the
1 2 p a s s e n g e r s and 3 c r e w m e m b e r s .
Investigation and Evidence
The weather r e p o r t two minutes a f t e r the
accident (1828 h o u r s ) was: sky partially
obscured, 800 s c a t t e r e d , e s t i m a t e d ceiling
3 000, o v e r c a s t ; visibility 2, light r a i n s h o w e r s
and fog; t e m p e r a t u r e 59, dewpoint 58; wind
c a l m ; a l t i m e t e r 29.86-Remarks: scattered
clouds variable to broken.
The a i r s p e e d c r o s s i n g the a i r p o r t bound-
a r y was reported a s 90 knots and touchdown on
the wet runway a s 900 feet f r o m the approach
end on the m a i n g e a r with the tail wheel off the
runway s u r f a c e . On a 4 000 foot d r y runway
this would have been safe, however, landing
a t this speed on a wet runway i s a m a r g i n a l
l C A 0 Ref: ~ ~ / 3 9 0
117
operation. Keeping the tail up on the DC-3 in
o r d e r to maintain good directional control and
to put m o r e weight on the m a i n g e a r f o r b e t t e r
braking i s a p r a c t i c e often used in landing.
Slnce the captain s t a t e d that the t a i l wheel was
not in contact with the runway until n e a r i t s
end, the speed a t touchdown m u s t have been
somewhat e x c e s s i v e i n o r d e r to p e r m i t keeping
the tail in the a i r f o r approximately 3 000 feet.
He a l s o s t a t e d that h e did not a t t e m p t t o ground-
loop because of the speed.
Wet runways affect braking action ad-
v e r s e l y . The captain r e p o r t e d h i s braking
effectiveness a s "poor to nil" and when this
condition was definitely established t h e r e was
not sufficient time o r distance remaining i n
which t o c a r r y out c o r r e c t i v e action.
Hlgh speed and resulting momentum
in the landing r o l l would r e t a r d dissipation
of the wing llft, a d v e r s e l y affecting braking
action and i n c r e a s i n g the distance r e q u i r e d
f o r stopping.
T h e r e was no mechanical f a i l u r e o r
malfunction in the a i r c r a f t o r i t s components,
including the braking s y s t e m , p r i o r to the
accident.
P r o b a b l e Cause
The probable c a u s e of this accident w a s
a n a p p r o a c h too high and too f a s t under the
existing c a l m wind-and wet runway condition
and the subsequent ineffective braking action.
 118 ICAO C i r c u l a r 5 0 - ~ N / 4 5

No. 26

Associated A i r w a y s Ltd., Lockheed 14-08, CF-TCI a i r c r a f t ,

c r a s h e d on t e s t flight a t Winterburn, A l b e r t a , 7 June 1955.
R e p o r t No. 55-28 r e l e a s e d by Canadian D e p a r t m e n t of T r a n s p o r t .
A i r S e r v i c e s B r a n c h , Civil Aviation Division.

Circumstances b a l l a s t and weighing 125 l b s , each. M o r e o v e r ,

The a i r c r a f t took off a t approximately
1700 h o u r s Mountain Standard T i m e on a local
t e s t flight c a r r y i n g a c r e w of 2 a n d 4 p a s s e n -
g e r s . The purpose of the flight was to t e s t the
single-engine p e r f o r m a n c e of the a i r c r a f t when
loaded to the m a x i m u m p e r m i s s i b l e weight f o r
take-off and to d e t e r m i n e the c o r r e c t power
setting and p e r f o r m a n c e . J u s t b e f o r e 1705 hours
w i t n e s s e s s t a t e d that they saw the a i r c r a f t t u r n
onto i t s back with a sudden c e s s a t i o n of engine
noise and white o r g r e y vapour w a s s e e n to
c o m e f r o m both engines a s i t dived i n a v e r y
s t e e p n o s e down attitude to the ground. F r o m
s t a t e m e n t s of w i t n e s s e s i t was deduced that it
was probable that the a i r c r a f t was below 1 000
f e e t when it turned onto i t s back. T h e a i r c r a f t
exploded on i m p a c t and caught f i r e . All the
occupants w e r e killed and the a i r c r a f t was
destroyed.
Investigation and Evidence
A m a j o r inspection (100 h o u r ) had
r e c e n t l y been c a r r i e d out on the a i r c r a f t by
the Company but had not been c e r t i f i e d in the
a i r c r a f t log books.
It was computed that the a i r c r a f t was
overloaded by an amount i n e x c e s s of 917 l b s .
T-
--h i s included four c e m e n t blocks c a r r i e d a s
i t a p p e a r e d that the c r e w w e r e not p r o p e r l y con-
v e r s a n t with loading r e q u i r e m e n t s and c e n t r e
of g r a v i t y limitations.
Although h a m p e r e d by f i r e d a m a g e ,
the engines and a i r - s c r e w s w e r e s t r i p p e d and
no evidence of malfunctioning was found.
The ignition switch was found with the
m a s t e r switch in the "offf1position. T h e m a s -
t e r switch was of the type that i s pulled out f o r
the "off" position.
No evidence was found of an e m e r g e n c y
situation having a r i s e n but i n view of a p r e v i o u s
e m e r g e n c y single-engine flight having been
c a u s e d by a n oil leak, i t i s possible t h a t such
might have r e o c c u r r e d s h o r t l y a f t e r take-off.
Weather was not c o n s i d e r e d to have
been a f a c t o r i n the accident.
P r o b a b l e Cause
F o r r e a s o n s that w e r e not conclusive-
ly d e t e r m i n e d , the a i r c r a f t a s s u m e d a n un-
usual position a t a n altitude above the ground
which was insufficient t o p e r m i t r e c o v e r y .
The a i r c r a f t was overloaded by a t l e a s t 900
l b s . and t h i s would r a i s e the stalling speed
and a f f e c t the controllability of the a i r c r a f t .

ICAO Ref: ~ ~ / 4 0 7
 ICAO C i r c u l a r 50-AN/45 119

No. 27

-P n n a i r rln -.---
-- R r a ~ i l S A . .* -Lockheed
- -- Constellation
- .
L-0-49.. P P - P D J .
c r a s h e d a t T r e s Bocas, 12.9 k m southwest of Asuncion National A i r p o r t ,
Asuncion, P a r a g u a y , on 16 June 1955. Released by the D i r e c t o r a t e Gene1
of Civil Aviation, P a r d ~ u a y .

(Additional c o m m e n t s and findings Investigation and Evidence

by B r a z i l , the State of R e g i s t r y ,
have been added a s footnotes to
the following r e p o r t r e l e a s e d by
P a r a g u a y , the State of O c c u r r e n c e . )
Circumstances
The w e a t h e r before the t i m e of the acci-
dent was a s follows:
0010 p a r t l y cloudy, visibility 1 5 kilo-
metres

T h e a i r c r a f t was on a scheduled flight O O Z O v , l a ? S S E 8 knots, p r e s s u r e

f r o m London to Buenos A i r e s with s t o p s a t
P a r i s , Lisbon, D a k a r , Recife, Rio d e Janeiro,
S%o Paulo and Asuncion, c a r r y i n g 14 p a s s e n -
g e r s and 10 c r e w . 1) At 0105 h o u r s ( l o c a l
t i m e ) the Constellation called the Asuncion
c o n t r o l t o w e r who c l e a r e d the flight to land on
Runway 02 and requested the a i r c r a f t to c a l l
when on final approach. The l a s t contact with
the flight was made a t 01 15 h o u r s . F r o m that
t i m e on a control tower employee r e p o r t e d
the a i r c r a f t moved t o w a r d s the south-southwe*.
He t r i e d to sight i t and noted that it headed to-
w a r d s the city, made a t u r n to the left and
a p p e a r e d to initiate i t s final straight-in ap-
p r o a c h . When sufficient t i m e f o r a landing had
e l a p s e d the employee called attention to the
l a c k of communication between the a i r c r a f t
and the control tower. He continued to look
out to the south where the a i r c r a f t would have
a p p e a r e d and s a w a sudden b u r s t of f l a m e n e a r
t h e P a r a g u a y A e r o Club, south of the a i r p o r t .
F i v e p a s s e n g e r s and t h r e e c r e w m e m b e r s s u r -
vived. The a l r c r a f t was completely d e s t r o y e d
by f i r e which broke out i m m e d i a t e l y a f t e r
impact.
1 ~ , z ,'. m b s .
.
0040 3/8 Sj 170 m e t r e s ; r a i n f e l l
f o r a few m i n u t e s just a t t h i s
t i m e and then c e a s e d completely.
0050 3/8 ST. 170 m e t r e s ; visibility
-
1 5 km; wind ENE 8 10 knots,
variable.
All information supplied to the a i r c r a f t
w a s provided by the P a n a i r do B r a z i l radio s t a -
tion. It was e n t i r e l y a c c u r a t e and in a c c o r d a n c e
with the r e c o r d s of the equipment a t the c o n t r o l
tower of Asuncion National A i r p o r t .
F r o m a n exdmlnation of the wreckage and
of the path flown by the a i r c r a f t , i t i s p r e s u m e d
that the a i r c r a f t was coming down a t a landing
angle on a t r a c k of 30 d e g r e e s , 2 ) c r o s s i n g the
T r e s B o c a s r o a d a t right angles. T h e p l a c e
w h e r e the c r a s h o c c u r r e d i s a t an elevation of
650 f e e t above s e a level. The a r e d is f r i n g e d
o n the southwest with t r e e s 1 5 m e t r e s high and
is c o v e r e d with banana and pineapple plantations.

1) "The flight plan, f o r the p a r t S%o Paulo-Asuncion of the f'light, w a s c l e a r e d IFR a t

5.400 m , off a i r w a y s , having a s a l t e r n a t i v e s GdleZo ( B r a z i l ) and L i m a (PerG)."

2) 'I. .. with a s m a l l r a t e of d e s c e n t , p r a c t i c a l l y a l m o s t in level flight. 'I

120 ICAO C i r c u l a r 50-AN/45 *

'The a i r c r a f t , c o m i n g down a t a n a n g l e of No. 1 p o r t e n g i n e w a s found 450 m e t r e s

a p p r o x i m d t e l y 50 hit a 1 2 m e t r e t r e e with t h e
t i p of i t s l e f t wing, 1 ) c a u s i n g a s e c t i o n of the
wing 1 . 5 m e t r e s long t o b r e a k o f f , 2) c o n t i n u e d
o n the s a m e p a t h u n t i l , 50 m e t r e s f r o m t h e f i r s t
i m p a c t , the p r o p e l l e r of o n e of t h e e n g i n e s c u t
a b r a n c h of a t r e e 8 m e t r e s f r o m the g r o u n d
a n d s e v e r a l c o c o n u t t r e e s w e r e c u t down o r
overturned. The r u d d e r and the verticdl sta-
b i l i z e r w e r e found a t a p o i n t 200 m e t r e s f r o m
the point of f i r s t i m p a c t . A o n e m e t r e s e c t i o n
of the r i g h t wing t i p w a s found 20 m e t r e s f u r -
t h e r o n a n d a l . 5 m e t r e s e c t i o n of t h e t a i l w a s
found t o the r i g h t of the a i r c r a f t p a t h .
The complete n o s e landing gear3) w a s
found 350 m e t r e s f r o m the point of f i r s t i m -
pact. Seventy m e t r e s f u r t h e r on, but some-
w h a t t o t h e l e f t , w a s t h e c o c k p i t with b o t h pan-
e l s a n d t h e e n t i r e l e f t landing g e a r . A p p r o x i -
r n a t e l y 7 0 % of t h e r i g h t wing a n d i t s e n t i r e
a i l e r o n w e r e found a t t h e s a m e l e v e l b u t t o t h e
r i g h t of t h e path.
F i n a l l y , 500 m e t r e s f r o m t h e point of
f i r s t impact, the a i r c r a f t c a m e into violent
c o n t a c t with a t r e e a t g r o u n d l e v e l , u p r o o t i n g
it, s o that the fuselage fell o v e r in a position
f a c i n g a b o u t 30° t o t h e l e f t of the p a t h of flight.
At t h i s point t h e f u s e l a g e a n d l e f t l a n d i n g g e a r
caught fire.
f r o m the point of f i r s t i m p a c t a n d t h e No. 2
p o r t e n g i n e a l i t t l e f u r t h e r on. T h e two s t a r -
b o a r d e n g i n e s w e r e found n e a r b y , t o the l e f t
of the f u s e l a g e .
T h e d u a l w h e e l of t h e r i g h t l a n d i n g g e a r
w a s found without m a j o r d a m a g e 150 m e t r e s
f r o m the point of f i n a l i m p a c t a n d a t a p p r o x i -
m a t e l y 15O f r o m t h e p a t h of t h e a i r c r a f t .
T h e c o - p i l o t a t t h e t i m e of t h e a c c i d e n t
stated that the a i r c r a f t was making a n instru-
m e n t a p p r o a c h 4 ) t o Runway 02 having b e e n
c l e a r e d b y t h e t o w e r . He s t a t e d t h a t t h e f i n a l
a p p r o a c h w a s b e i n g m a d e a t 1 3 0 k n o t s a n d the
a i r c r a f t had b e e n flying i n cloud. 5 , T h e a l t i m -
e t e r s h o w e d 820 f e e t t h e l a s t t i m e h e l o o k e d
a t the i n s t r u m e n t p a n e l . He thought t h a t t h e y
had deviated excessively f r o m the approach
p a t h owing t o t h e wind w h i c h w a s p r o b a b l y
s t r o n g e r than estimated. Visibility a few s e c -
o n d s b e f o r e the a c c i d e n t w a s z e r o . T h e a i r c r a f t
h a d b e e n f u n c t i o n i n g n o r m a l l y up until the a c c i -
dent.
T h e s t e w a r d r e m e m b e r e d t h a t the f l i g h t
radio operator commented that he had received
a r a d i o r e p o r t t h a t A s u n c i o n w a s f r e e of c l o u d
and that when the tower was contacted i t r e p o r t -
e d a 300 m e t r e c e i l i n g .

1 ) "At t h i s t i m e t h e f l i g h t l e v e l of t h e p l a n e w a s 1 9 5 m e t r e s , i. e . b e l o w t h e m i n i m u m p r e s c r i b e d
f l i g h t l e v e l , which i s 254 m e t r e s f o r a n i n s t r u m e n t a p p r o a c h o n the 02 runway.

2 ) " T h e v e s t i g e s o n the t r e e s i n d i c a t e d t h a t t h e p l a n e , s h o r t l y a f t e r l o s i n g t h e wing t i p , i n c l i n e d

s u d d e n l y t o w a r d s t h e l e f t a b o u t 28 d e g r e e s , and I n c r e a s e d s u b s t a n t i a l l y t h e a n g l e of d e s c e n t . "

3) It., . t h e n o s e wheel h i t the ground and c a u s e d t h e n o s e s e c t i o n to b r e a k a p a r t f r o m the f u s e -

l a g e , d i s c o n n e c t i n g a l s o the i n s t r u m e n t p a n e l , the c o c k p l t f l o o r and t h e p e d e s t a l with the
e n g i n e c o n t r o l s . A l i t t l e b e f o r e t h e n o s e w h e e l , e n g l n e No. 2 a l s o h i t t h e g r o u n d a n d w a s
disconnected and impelled f o r w a r d , ... "

"At t h i s t l m e , o r a l i t t l e b e f o r e , t h e p l a n e , while s l i d i n g o n the g r o u n d b e g a n to r o t a t e a r o u n d

i t s v e r t i c a l a x i s , c o u n t e r c l o c k w i s e , a n d f i n a l l y c a m e t o r e s t a t a n a n g l e of 110 d e g r e e s .

4 ) "When t h e p l a n e w a s o n i t s final d p p r o a c h t r a c k , t h e c o - p i l o t r ~ i s e dh i s a r m i n o r d e r t o put

t h e landing l i g h t s on. At t h i s m o m e n t , he h e a r d the p i l o t s a y : " I n c r e a s e p o w e r , we a r e t o o
low. T h e co-pilot l o w e r e d h i s h a n d s to i n c r e a s e p o w e r , g l a n c e d a t t h e a l t i m e t e r which w a s
i n d i c a t i n g '247 m e t r e s ' a n d a t t h i s i n s t a n t t h e p l a n e h i t the t r e e .

5 ) "The pilot told the co-pilot t h a t h e would m d k e a n outbound t r a c k of 1 m i n u t e a n d a half to

c o m p e n s a t e f o r the wind."
 ICAO C i r c u l a r 50-AN/45 121

Another witness stated that the e n t i r e An e r r o r i n timing r e s u l t e d i n the final approdch

a r e a of the accident was obscured by dense
clouds.
Probable Cause l )
The accident was due to a piloting e r r o r
i n making the approach c i r c u i t on instruments.
being initiated a t too g r e a t a distance f r o m the
a i r p o r t . Proof of this was provided by the fact
that the landing g e a r was found extended, the
flaps down, the m i x t u r e control s e t a t "rich",
a l l of which indicated that the a i r c r a f t w a s in
the ready to land condition.

1) "The accident was caused by personnel failure: pilot e r r o r . The pilot did not follow the
recommended procedure f o r instrument final approach clnd he descended below the height
p r e s c r i b e d i n the final approach c h a r t .

Concurring f a c t o r s w e r e :

1. Flight fatigue, due to e x c e s s flight time. T h e pilot flew in the preceding months
an a v e r a g e of 113 hours.

2. The c r e w did not follow the normal cockpit p r o c e d u r e , The co-pilot did not s e t
his a l t i m e t e r to the received a l t i m e t e r setting.

3. Bad layout of the face of the chronometer of the i n s t r u m e n t panel, which did make
the readings m o r e d i f f i ~ u l t . ~ '

ICAO Ref: ~ R / 3 9 8
 122 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
No. 28
B r i t i s h O v e r s e a s Airways Corporation, De Havilland Dove 104, G-ALTM, c r a s h landed
outside the w e s t e r n boundary of London Airport, England, on 22 June 1953. Report
dated 9 December 1955 r e l e a s e d by Ministry of T r a n s p o r t and Civil Aviation (U. K.
Circumstances
The a i r c r a f t c a r r y i n g the captain and
two photographers was on a filming flight of
London Airport. T h r e e r u n s o v e r the a i r p o r t
had been successfully completed and the a i r -
c r a f t was positioning for a fourth when the
pilot noticed a d e c r e a s e i n a i r s p e e d . During
a check to a s c e r t a i n the c a u s e a low oil p r e s -
s u r e reading was o b s e r v e d and because of this,
combined with rough running, the pilot decid-
ed to shut down the p o r t engine. A single-
engined approach was commenced with the in-
tention of landing on Runway 10 Right. Shortly
a f t e r w a r d s the s t a r b o a r d engine c e a s e d to de-
velop power and the a i r c r a f t was c r a s h landed
in d a r k n e s s a t approximately 2152 h o u r s G r e e n -
wich Mean Time. No one was injured and t h e r e
was no f i r e .
Investigation and Evidence
The captain of the a i r c r a f t had made
a r r a n g e m e n t s t o m a k e a s e r i e s of day and
night colour f i l m s of the approaches, runways
and take-off paths a t London Airport. A s u c -
c e s s f u l 2 1/2 hour filming flight was completed
during the afternoon. L a t e r t h a t day the cap-
tain, with two photographers, boarded the a i r -
c r a f t f o r a filming flight in d a r k n e s s . The a i r -
c r a f t took off a t 2106 h o u r s on Runway 28 Right.
Two approaches, low r u n s and overshoots w e r e
completed on Runway 28 Right followed by a
low r u n o v e r Runway 10 Right. During the
whole of the flight the a i r c r a f t was in radiote-
lephony contact with London Tower and r a d a r
control was used to a s s i s t the pilot in making
t h e runs. At 2147 h o u r s when the a i r c r a f t was
6 m i l e s south-south-west of London A i r p o r t a t
1 500 feet i t was d i r e c t e d on to a heading of
3300M to bring i t on to a right hand b a s e leg
for an approach t o Runway 10 Right. When
established on this heading the pilot noticed
that the a i r s p e e d had d e c r e a s e d f r o m 128 to
110 knots although the power settings had not
been a l t e r e d . A check proved that this was
not caused by i n c r e a s e d d r a g due to drooping
u n d e r c a r r i a g e o r flaps. The pilot then checked
the engine i n s t r u m e n t s and h r s t a t e s that he ob-
s e r v e d a low oil p r e s s u r e and a high oil t e m -
p e r a t u r e on the port engine gauge. The photo-
g r a p h e r , to whom the pilot pointed out these
1
a b n o r m a l readings, s t a t e s that t h e gauge t o
which his attention was drawn was thatof the
s t a r b o a r d engine. The pilot then p a s s e d the
following m e s s a g e s t o London Tower; they
were electrically recorded:-
2149 h r s . " T a r e Mike t o Tower 1'11 do
this r u n and then 1'11 have
to land I ' m getting failing
oil p r e s s u r e on the s t a r -
b o a r d enginett.
215 1 h r s. " T a r e Mike I'm feathering".
London Tower informed him that he was t h r e e
m i l e s out on final approach and c l e a r to land,
At 2152 h o u r s the pilot r e p o r t e d "failing power
on t h e o t h e r enginett followed by the final m e s -
s a g e I t c r a s h landing I ' m sorryI1.
Shortly a f t e r noticing the low oil p r e s -
s u r e reading the pilot s t a t e s that he c a r r i e d
out the approach check, s e l e c t e d 20° of f l a p
and a s rough running was developing he decid-
ed t o take feathering action. He s t a t e s that he
moved the p o r t pitch control l e v e r back through
the feathering gate but he did not p r e s s the feath-
e r i n g button. He f u r t h e r s t a t e s that when the
propeller stopped rotating he switched off the
port engine ignition switches and the rough run-
ning ceased. He i n c r e a s e d the power setting
for the s t a r b o a r d engine and lowered t h e under-
c a r r i a g e in p r e p a r a t i o n for a single-engined
landing; a f u r t h e r i n c r e a s e in t h e s t a r b o a r d
engine power setting r e s u l t e d in a noticeable
i n c r e a s e in power output. Shortly a f t e r w a r d s
m a r k e d vibration developed and the r a t e of
descent i n c r e a s e d due to failing power f r o m
the s t a r b o a r d engine. The r a t e of descent was
checked a s much a s a s a f e a i r s p e e d would allow
but without engine power it was impossible t o
r e a c h the runway. After warning his p a s s e n -
g e r s and Control the pilot c r a s h landed the a i r -
c r a f t just s h o r t of the f i r s t b a r of the approach
lights.
The A e r o d r o m e F i r e S e r v i c e was warned
inlmediately of the impending c r a s h by Air T r a f -
fic Control and the f i r e and r e s c u e vehicles left
their station a s the a i r c r a f t c r a s h landed. Never-
t h e l e s s , about 15 minutes elapsed before they
a r r i v e d a t the s c e n e of t h e accident which was
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
just outslde the a i r p o r t boundary, r h l s was
due t o a 2 1/2 m l l e d e t o u r o v e r winding c l a s s
2 r o a d s i n o r d e r t o c r o s s a r i v e r which f o r m s
the a i r p o r t boundary.
E x a m i n a t i o n of the w r e c k a g e s h o w e d t h a t
both o u t e r wings h a d b e e n t o r n off a f t e r s t r i k -
i n g t e l e g r a p h p o l e s and t h a t t h e m a i n w r e c k a g e ,
c o n s i s t i n g of t h e f u s e l a g e a n d c e n t r e p l a n e , h a d
c o m e t o r e s t 10 y a r d s f r o m t h e f i r s t c r o s s b a r
of t h e a p p r o a c h l i g h t s y s t e m . T h e e n g i n e s r e -
m a i n e d i n position and did not appear to have
suffered m u c h c r a s h damage although a l l t h r e e
b l a d e s of both p r a p e l l e r s w e r e b e n t , i n d i c a t i n g
s o m e d e g r e e of r o t a t i o n o n i m p a c t . T h e p o r t
engine cowlings w e r e clean but the s t a r b o a r d
engine cowlings w e r e splashed with engine oil
which h a d a l s o b e e n t h r o w n b a c k o v e r t h e f u s e -
lage a n d s t a r b o a r d tailplane during flight.
The engine controls in the cockpit w e r e
f o u n d with t h e following s e t t i n g s : -
P o r t Engine S t a r b o a r d Engine
Throttle Lever
Fully closed Fully open
Pitch Control L e v e r
"Min. R. P . M . " "Max. R . P . M . "
T h e e v i d e n c e i n d i c a t e d t h a t both p o r t a n d s t a r -
b o a r d e n g i n e s h a d b e e n a d e q u a t e l y s u p p l i e d with
fuel and oil.
T h e two e n g i n e s w e r e r e m o v e d f r o m t h e
a i r f r a m e and sent to the manufacturers for
detailed examination. The p o r t engine w a s
m o u n t e d o n a t e s t bed arid given a t e s t r u n f o r
one hour. This test proved to be satisfactory
a n d showed that the engine w a s in n o r m a l work-
ing o r d e r .
E x a m i n a t i o n of t h e s t a r b o a r d e n g i n e s h o w -
ed that the crankshaft had f r a c t u r e d a t the for-
w a r d w e b of No. 3 c r a n k p i n a n d t h a t No. 4
crankpin had cracked. Both t h e f r a c t u r e and
t h e c r a c k s h o w e d e v i d e n c e of s l o w f a t i g u e . In
both c a s e s t h e r e w e r e f a t i g u e n u c l e i a d j a c e n t
t o a plugged h o l e which i s c o n s i d e r e d t o h a v e
been the primary s t r e s s r a i s e r .
Micro examination and h a r d n e s s t e s t s
s h o w e d t h a t t h e m a t e r i a l a n d h e a t t r e a t m e n t of
the crankshaft were satisfactory.
A s t r i p e x a m i n a t i o n of t h e p o r t p r o p e l l e r
by t h e m a n u f a c t u r e r s r e v e a l e d n o e v i d e n c e of a
p r e - c r a s h failure. As f a r a s could be d e t e r -
m i n e d the f e a t h e r i n g m e c h a n i s m w a s in w o r k i n g
order.
123
It h a s b e e n e s t a b l i s h e d t h a t t h e r e w a s
a m a j o r m e c h a n i c a l f a i l u r e of t h e s t a r b o a r d
englne before the c r a s h landing. Despite the
p i l o t ' s s t a t e m e n t t o t h e c o n t r a r y , t h e r e is
a m p l e e v i d e n c e t h a t s y m p t o m s of t h e i m p e n d -
ing f a i l u r e w e r e i n d i c a t e d b y low o i l p r e s s u r e
a n d high o i l t e m p e r a t u r e on t h e s t a r b o a r d e n -
gine gauge a n d t h a t t h e c o m p l e t e f a i l u r e w a s
b r o u g h t a b o u t by r u n n i n g t h e f a i l i n g e n g i n e a t
a l m o s t m a x i m u m p o w e r i n s t e a d of s h u t t i n g i t
down.
The pilot c o r r e c t l y identified the faulty
e n g i n e i n h i s r a d i o t e l e p h o n y r e p o r t but t h e r e -
a f t e r s h u t down t h e s o u n d e n g i n e w h i c h w a s
c a p a b l e of giving f u l l p o w e r w i t h n o r m a l o i l
p r e s s u r e a n d t e m p e r a t u r e . I t is d i f f i c u l t t o
find a n explanation f o r this m i s t a k e , particu-
l a r l y in v i e w of t h e p i l o t ' s e x p e r i e n c e as a n
i n s t r u c t o r o n t h e t y p e of a i r c r a f t . I t i s n o t e d
t h a t t h e p i l o t w a s flying f r o m t h e l e f t h a n d s e a t
although h e was m o r e accustomed to fly f r o m
the right hand s e a t , that the engine i n s t r u m e n t s
In t h i s a i r c r a f t w e r e g r o u p e d o n t h e r i g h t h a n d
panel away f r o m the engine c o n t r o l s and that a
l o w o i l p r e s s u r e i n t h e s t a r b o a r d e n g i n e would
be i n d i c a t e d by t h e l e f t h a n d p o i n t e r of t h e s t a r -
board oil p r e s s u r e / t e m p e r a t u r e gauge. It is
p o s s i b l e t h a t within t h i s c o m b i n a t i o n of c i r c u m -
s t a n c e s lay a s e e d f r o m which confusion grew.
I n v e s t i g a t i o n of t h e d e f e c t i n t h e s t a r -
board engine showed that the crankshaft had
f a i l e d a s a r e s u l t of f a t i g u e c r a c k s . D u r i n g
t h e c o u r s e of t h i s i n v e s t i g a t i o n a n o t h e r a c c i -
d e n t o c c u r r e d t o a Dove a i r c r a f t i n w h i c h t h e r e
h a d a l s o b e e n a c r a n k s h a f t f a i l u r e cf a s i m i l a r
n a t u r e . Although t h e s e two c a s e s a r e t h e o n l y
o n e s a s s o c i a t e d with a c c i d e n t s , a n a d d i t i o n a l
eight crankshafts have manifested s y m p t o m s
of f a i l u r e d u r i n g flight. A l t o g e t h e r t h e r e h a v e
b e e n t h i r t y - t w o c a s e s of c r a n k s h a f t s d e v e l o p i n g
f a t i g u e c r a c k s s i n c e 1950, m o s t of t h e m d i s -
covered during inspection a t overhaul. Since
D e c e m b e r 1951 a l l new c r a n k s h a f t s h a v e b e e n
m a n u f a c t u r e d with s t r e n g t h e n e d w e b s . A m o d -
ification removing the s c r e w t h r e a d s f r o m the
plugged h o l e s w a s l a t e r i n t r o d u c e d ; t h i s a p p l i e d
t o b o t h new a n d o l d t y p e c r a n k s h a f t s . T h e r e
i s t o d a t e n o r e c o r d of a c r a c k having d e v e l o p e d
a t a plugged hole in a strengthened crankshaft
but s e v e r a l h a v e o c c u r r e d i n t h e m o d i f i e d p r e -
1951 c r a n k s h a f t s . S i n c e t h e a c c i d e n t t h e e n -
gine manukacturer s have reproduced a c h a r a c -
t e r l s t i c f a i l u r e by f a t i g u e l o a d i n g a c r a n k t h r o w
i n a s p e c i a l r i g . T h e knowledge g a i n e d f r o m
this t e s t h a s suggested new methods for r e s t o r -
i n g t h e r e d u c t i o n i n f a t i g u e s t r e n g t h c a u s e d by
the p r e s e n c e of the plugged h o l e s . When t h e
t e s t s a r e complete further modification action
w i l l be c o n s i d e r e d .
124 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
The weather conditions had no bearing
on the cause of the accident.
The pilot's licence had expired although
h i s m e d i c a l a s s e s s m e n t was in o r d e r . The
expired licence did not include an a i r c r a f t
type rating in Group I.
Probable Cause
The accident was caused by an e r r o r on
the p a r t of the pilot who shut down the p o r t
engine instead of the s t a r b o a r d engine in
which trouble was developing. Subsequently,
a complete power f a i l u r e of the s t a r b o a r d en-
gine o c c u r r e d .
ICAO Ref: ~ ~ / 4 2 2
Recommendations
It i s recommended that:-
i ) The attention of a l l concerned with
the operation of Gipsy Queen 70
engines be drawn to t h e possibility
that a low oil p r e s s u r e reading m a y
be indicative of a fatigue c r a c k i n
the crankshaft.
i i ) The adequacy of the existing a c c e s s
for Aerodrome F i r e Service vehicles
to the land s e c t o r adjoining the west-
e r n boundary of London A i r p o r t be
reviewed.
 ICAO C i r c u l a r 50-AN/45 125

No. 29

T r a n s W o r l d A i r l i n e s , I n c . , Dou::las DC-3 a n d B a k e r F l y i n g S e r v i c e , C e s s n a
140-A a i r c r a f t . collided 2 m i l e s N N W of F a i r f a x A i r ~ o r C t ontrol Tower.
K a n s a s City, K a n s a s , Missouri, on 1 2 J u l y 1955. C i v i l A e r o n a u t i c s B o a r d
(USA) Accident Investigation R e p o r t SA-307, F i l e No. 1-0078 r e l e a s e d
1 1 J a n u a r y 1956

Circumstances clearance to m a k e another simulated low

T h e I ' r a n s World A i r l i n e s 1 DC-3 w a s
s c h e d u l e d f o r a pilot r e q u a l i f i c a t i o n c h e c k
fllght. T h e a i r c r a f t took off a t 100k h o u r s
C e n t r a l Standard T i m e f r o m the Kansas City
M u n i c ~ p a lA i r p o r t , K a n s a s City, a n d r e q u e s t -
e d c l e a r a r ~ c eto c a r r y out the f i r s t p o r t i o n of
t h e c h e ~ kwhich w a s t o include two touch-and-
go landings a t F a i r f a x A i r p o r t . T h e flight w a s
c l e a r e d by F a i r f a x a n d a t a p p r o x i m a t e l y 1011
h o u r s touched down o n Runway 35 a t F a i r f a x
following which a n o r m a l take-off w a s m a d e .
On r e a c h i n g 1 050 f e e t power w a s r e d u c e d to
39" of m a n i f o l d p r e s s u r e a n d when a t 1 250
f e e t a n d a t a n i n d i c a t e d a i r s p e e d of 105 knots,
power w a s f u r t h e r r e d u c e d t o 32" manifold p r e s -
s u r e a n d p r o p e l l e r s e t t i n g s w e r e changed f r o m
2 450 r p m t o 2 050 r p m . A l e f t climbilig t u r n
w a s then begun. At a p p r o x i n ~ a t e l y150 k n o t s ,
on a heading of 200 d e g r e e s and a t a n a l t i t u d e
of between 1 750 a n d 1 900 f e e t , the p i l o t s h e a r d
a n o i s e s i m i l a r t o a n explosion a n d f e l t t h e a i r -
c r a f t s w e r v e t o t h e left. I m m e d i a t e l y t h e F a i r -
f a x t o w e r c o n t r o l l e r c a l l e d the flight a n d a d v i s e d
t h a t h e thought i t h a d collided with a C e s s n a .
T h e DC-3, which h a d been s u b s t a n t i a l l y d a m -
aged, l a n d e d s a f e l y a t F a i r f a x A i r p o r t . N e i t h e r
of t h e two o c c u p a n t s w a s i n j u r e d .
At 0830 h o u r s , the n l o r n i n g of the s a m e
d a y , a Cessr.a 140-A h a d d e p a r t e d the Municipal
A i r p o r t o n a n i n s t r u m e n t t r a i n i n g flight. At
0945 t h i s a i r c r a f t w a s c l e a r e d by F a i r f a x t o w e r
t o m a k e a s i m u l a t e d low f r e q u e n c y r a n g e a p -
p r o a c h a n d w a s a d v i s e d t o r e p o r t upon c o m p l e -
tion of i t s p r o c e d u r e t u r n inbound. I t r e p o r t e d
a s d i r e c t e d , the a i r c r a f t p a s s e d the r a n g e s t a -
tion, e x e c u t e d a m i s s e d a p p r o a c h p r o c e d u r e
a n d d i s a p p e a r e d f r o m the c o n t r o l t o w e r ' s view,
heading west. At 1002 the C e s s n a again c a l l e d
the F a i r f a x t o w e r , gave i t s position a s o v e r t h e
r a n g e s t a t i o n , a l t i t u d e 3 000 f r e t , and r e q u e s t e d
frequency range approach. The a i r c r a f t was
c l e a r e d t o Runway 1 3 a n d r e q u e s t e d t o t l c a l l
p r o c e d u r e t u r n inbound". T h i s w a s acknowl-
e d g e d a n d w a s t h e l a s t r a d i o c o n t a c t with t h e
a i r c r a f t . T h e C e s s n a did not r e p o r t inbound.
At 1014 t h e c o n t r o l l e r s o b s e r v e d t h e TWA
flight n o r t h of t h e t o w e r m a k i n g a t u r n t o t h e
southwest and saw yellow objects falling
below a n d behind it. A s t h e C e s s n a w a s
yellow they concluded t h a t i t w a s involved
i n a collision. T h e two o c c u p a n t s of t h e
C e s s n a w e r e fatally injured.
Investigation a n d E v i d e n c e
The Cessna sustained severe damage
d u r l n g t h e inflight c o l l i s i o n and s u b s e q u e n t
ground i m p a c t . E x a m i n a t i o n of t h e e n t i r e
w r e c k a g e a c c o u n t e d f o r a l l c o m p o n e n t s of
the a i r c r a f t a n d no e v i d e n c e w a s found of
s t r u c t u r a l f a i l u r e o r malfunctioning p r i o r
t o t h e collision.
The C e s s n a wreckage was t r a n s p o r t e d
t o a suitable location where i t was laid out
for a m o r e detailed examination in an effort
t o d e t e r m i n e t h e m a n n e r i n which t h e two a i r -
craft c a m e together. The m o s t significant
of m a n y inflight i m p a c t m a r k i n g s w a s a s e r i e s
of eIeven p r o p e l l e r c u t s on t h e l e f t wing, cabin,
a n d r i g h t wing. T h e s e w e r e e s s e n t i a l l y p a r -
a l l e l a n d a l m o s t evenly s p a c e d . T h e f o r c e of
the c u t s d e s t r o y e d t h e s t r u c t u r a l i n t e g r i t y of
both wings while t h e a i r c r a f t w a s i n flight
a n d i n s u c h a m a n n e r t h a t the l e f t wing w a s
s e v e r e d i n five p i e c e s a n d the r i g h t wing i n
two. E x a m i n a t i o n of t h e c u t s r e v e a l e d t y p i -
c a l skin c u r l i n g s a n d f e a t h e r i n g a s s o c i a t e d
with high-speed c u t s m a d e by t h e DC-3's l e f t
p r o p e l l e r r o t a t i n g clockwise a s i t m o v e d o v e r
the C p s s n a f r o m l e f t t o r i g h t .

1) T h e K a n s a s C i t y Municipal A i r p o r t a n d t h e F a i r f a x A i r p o r t a r e about 1-1/2 m i l e s a p a r t a n d

s e p a r a t e d by t h e N I i s s o u r i R i v e r .
126 ICAO C i r c u l a r 5 0 - ~ N / 4 5
It was determined that gouges and
s c r a t c h e s on t h e b l a d e s of t h e C e s s n a p r o p e l -
l e r w e r e m a d e when t h e p r o p e l l e r c o n t a c t e d
t h e l e a d i n g e d g e a n d b o t t o m s u r f a c e of t h e
D C - 3 ' s l e f t wing.
T h e m a j o r d a m a g e t o t h e DC-3 w a s con-
fined to the left propeller, the left oil cooler
s c o o p , a n d t h e l e f t wing o u t b o a r d of t h e n a c e l l e .
T h e l e a d i n g edge of t h i s wing w a s b a d l y d a m -
a g e d a n d two p r o p e l l e r c u t s w e r e found in i t .
O t h e r p o r t i o n s of t h e wing b o r e n u m e r o u s scuff
m a r k s , c u t s a n d s c r a t c h e s . Blue a n d y e l l o w
p a i n t , t h e c o l o r s c h e m e of t h e C e s s n a , w e r e
c ~ b s e r v e di n m a n y p l a c e s . S m a l l p i e c e s of t h e
l e f t a n d r i g h t wing p a n e l s of t h e C e s s n a w e r e
hanging f r o m t h e DC-3 a n d e m b e d d e d in t e a r s
n e a r i t s l e f t landing l i g h t . T h e l e f t p r o p e l l e r
b l a d e s of t h e DC-3 w e r e gouged a l o n g t h e i r
l e a d i n g e d g e s a n d both s i d e s of t h e b l a d e s s h o w -
ed yellow and blue paint. The lower and out-
b o a r d l e a d i n g e d g e s of t h e l e f t o i l c o o l e r s c o o p
w e r e c r u s h e d r e a r w a r d and a l s o showed evi-
d e n c e of paint f r o m t h e C e s s n a . E x a m i n a t i o n
of t h e DC-3 a n d t e s t i m o n y of t h e c r e w r e v e a l e d
t h e r e w a s no m a l f u n c t i o n o r f a i l u r e of t h e a i r -
c r a f t o r i t s components p r i o r t o the initial i m -
pact.
E x a m i n a t i o n of t h e C e s s n a V H F r a d i o
t r a ~ l s m i t t e rr e v e a l e d t h a t t h e s h a f t of t h e f r e -
quency selector switch was displaced r e a r w a r d
a n d j a m m e d . It c o u l d be r o t a t e d a d i s t a n c e of
a p p r o x i r n a t e l y one f r e q u e n c y s e l e c t i o n only.
T h e s w i t c h w a s i n a p o s i t i o n t o s e l e c t 119.1 m c . ,
t h e f r e q u e n c y n o r m a l l y u s e d in c o n t a c t i n g t h e
F a i r f a x tower. The VHF r e c e i v e r was badly
c r u s h e d by i m p a c t s o t h a t t h e t u n i n g c o n d e n s e r
w a s d e f o r m e d a n d the f i x e d a n d m o v a b l e p l a t e s
were p r e s s e d together. The frequency setting
of t h i s r a d i o u n i t c o u l d not b e d e t e r m i n e d .
T h e low f r e q u e n c y r e c e i v e r of t h e C e s s n a
a i r c r a f t sustained s e v e r e impact damage. The
s e l e c t o r switch was s e t to "range" position and
jammed. Examination r e v e a l e d that the unit
w a s j a m m e d on 355 k c . , a p p r o x i m a t e l y t h a t of
t h e K a n s a s C i t y low f r e q u e n c y r a n g e (359 k c . ) .
T h e C e s s n a w a s e q u i p p e d to t r a n s m i t or1
V H F f r e q u e n c i e s 1 1 8 . 3 m c . , 119. 1 m c . , 122.1
m c . , 1 2 2 . 5 m c . , a n d 1 2 1 . 5 m c . I t could r e -
c e i v e on t h e s e f r e q u e n c i e s a s w e l l a s on c o m m o n
low f r e q u e n c i e s . On t h e day of t h e a c c i d e n t t h e
c r e w of the C e s s n a r e p o r t e d t o t h e F a i r f a x t o w e r
o v e r t h e low f r e q u e n c y r a n g e s t a t i o n a n d a s k e d
p e r m i s s i o n to make the approach. This was
l e a r n e d by e x a m i n a t i o n of t h e r e c o r d i n g s m a d e
of a l l t r a n s m i s s i o n s on t h i s f r e q u e n c y in t h e
nearby municipal tower.
.
The F a i r f a x tower was equipped with
numerous transmitting and receiving f r e -
q u e n c i e s . With r e s p e c t t o t h e r e q u e s t f o r
t h e s i m u l a t e d i n s t r u m e n t a p p r o a c h m a d e by
the C e s s n a c r e w , however, the tower an-
s w e r e d o n 1 1 9 . 1 mc., w i t h a p o r t i o n of t h e
r e p l y being t r a n s m i t t e d s i m u l t a n e o u s l y o n
278 k c . u n t i l t h a t t r a n s m i t t e r k e y w a s o p e n e d ,
ending t h e t r a n s m i s s i o n o n t h a t f r e q u e n c y .
T h i s w a s done during t h e t r a n s m i s s i o n just
b e f o r e t h e p o r t i o n when t h e C e s s n a w a s r e -
q u e s t e d t o r e p o r t inbound o n i t s p r o c e d u r e
turn. Investigation disclosed that the low
frequency r e c e i v e r was tuned to the Kansas
C i t y low f r e q u e n c y r a n g e a t t h e t i m e of t h e
a c c i d e n t ; h o w e v e r , if t h e C e s s n a w a s r e -
c e i v i n g o n 278 k c , o n l y a t t h e t i m e t h e c l e a r -
a n c e w a s i s s u e d , i t s c r e w would not h a v e
h e a r d t h e i n s t r u c t i o n t o r e p o r t on t h e p r o c e -
d u r e t u r n inbound. If t h e V H F r e c e i v e r w a s
t u n e d t o 1 1 9 . 1 , t h e p i l o t s would h a v e h e a r d
the complete clearance.
T h e c r e w of t h e DC-3 t o o k off f r o m
K a n s a s C i t y M u n i c i p a l A i r p o r t a t 1001 u s i n g
tower frequency 118.3 m c . After climbing
t o a b o u t 2 000 f e e t t h e y c h a n g e d t o t h e F a i r f a x
t o w e r f r e q u e n c y of 119. 1 m c . a n d r e q u e s t e d
c l e a r a n c e to enter the F a i r f a x traffic pattern
f o r Runway 35. T h e DC-3 c r e w c o u l d not
h e a r communication between the tower and
the C e s s n a on 119.1 m c . because i t o c c u r r e d
s h o r t l y a f t e r 1002 h o u r s while t h e DC-3 w a s
st111 t u n e d t o 118. 3 rric. l ' h r c r e w of t h e
DC-3 a l s o s t a t e d t h , ~ tt h e y d i d not know t h a t
t h e C e s s n a w a s m a k i n g the a p p r o a c h .
T h e K a n s a s C i t y low f r e q u e n c y r a n g e
station is located . 7 statute m i l e s northwest
f r o m t h e a p p r o a c h end of Runway 13. T h e
low f r e q u e n r y r a n g e i t ~ s t r u r n t n ta p p r o a c h
p r o c e d u r e u s e d by B a k e r F l y i n g S e r v i ~ ep r o -
vides that the aircr'lfr p a s s over the range
s t a t i o n a t 3 000 f e e t , t h e n p r o c e e d o u t b o u ~ l d
on t h e n o r t h w e s t r a n g e l e g (328 d e g r e e s ) f o r
approximately seven m i l e s . It then r e q u i r e s
a p r o c e d u r e t u r n o n t h e e a s t s i d e of t h e r a n g e
l e g a n d r e t u r n t o t h e low f r e q u e n c y r a n g e s t a -
t ~ o non t h e s a m e ler; u s i n g a p p r o x i m a t e l y a
r e c i p r o c a l c o u r s e . During this t i m e a de-
s c e n t i s m a d e t o 1 600 f e e t .
The approved VFR departure pattern
on Runway 3 5 of the F a i r f a x ' A i r p o r t f o r a i r -
c r a f t a b o v e I 2 500 pounds g r o s s weight p r e -
s c r i b e s a left turn a s soon a s practicable
a f t e r take-off t o a m a g n e t i c h e a d l n g of 330
d e g r e e s , c l i n l b i n g t o a t l e a s t 2 000 f e e t
b e f o r e m a k i n g any o t h e r t u r n s o r p r o c e e d i n g
on c o u r s e .
 ICAO C i r c u l a r 5 0 - ~ N / 4 5
During the accldent period t h e r e w e r e
two c o n t r o l l e r s on duty in the F a i r f a x tower.
Traffic was light and weather conditions w e r e
c l e a r with v i s i b ~ l i t yapproximately 10 n.11es.
The approach controller s t a t e d that when the
C e s s n a r e q u e s t e d the second simulated i n s t r u -
ment approach he i s s u e d t h e c l e a r a n c e and had
p r e p a r e d a p r o g r e s s s t r i p f o r the flight. The
s t r i p had s p a c e s for t h e t i m e the flight r e p o r t e d
inbound on the p r o c e d u r e t u r n and t h e a r r i v a l
t i m e o v e r the r a n g e inbound. The controller
noted that t r a n s m i s s i o n s f r o m the C e s s n a w e r e
a little weak. He s t a t e d that while issuing the
c l e a r a n c e he t e r m i n a t e d the t r a n s m i s s ~ o non
278 kc. feeling s u r e that t h e a i r c r a f t was l i s -
tening on 119. 1 m c . frequency. The flight a c -
knowledged the c l e a r a n c e .
The local c o n t r o l l e r in the m e a n t i m e was
controlling other traffic, including the DC-3.
He testified that a f t e r the DC-3 b e c a m e a i r -
b o r n e following the touch-and-go landing a t
F a i r f a x , h e a s k e d the other c o n t r o l l e r if t h e
C e s s n a had r e p o r t e d on i t s p r o c e d u r e turn,
noting that the t i m e had not been r e c o r d e d on
the p r o g r e s s s t r i p . Informed that it had not,
both c o n t r o l l e r s , realizing i t was an i m p o r t a n t
traffic f a c t o r , looked f o r the C e s s n a in the a r e a
of t h e range station. Neither saw i t but both
w e r e able to s e e the DC-3 in a left climbing
turn north of the tower. The local controller
then t u r n e d to check t h e separation between t h e
DC-3 and another C e s s n a making touch-and-go
landings. Noting t h e r e was good s e p a r a t i o n h e
again looked f o r the C e s s n a belonging to the
Baker Flying S e r v i c e . He then saw t h e DC-3
just northwest of the r a n g e station and a t t h e
s a m e t i m e saw yellow objects falling below and
behind it. At no t i m e was advisory information
offered either t h e DC-3 c r e w o r the C e s s n a
c r e w r e l a t i v e to the p r e s e n c e and activity of
the o t h e r .
During the public hearing the officials of
Baker Flying S e r v i c e testified that under a con-
t r a c t u a l a g r e e m e n t with TWA they gave an in-
s t r u m e n t flight training c o u r s e to the a i r l i n e ' s
newly h i r e d f i r s t o f f i c e r s in o r d e r that t h e s e
p e r s o n s could obtain a CAA i n s t r u m e n t rating.
The p r o g r a m included s u p e r v i s e d flight during
which the student p r a c t i s e d I F R (Instrument
1) CAA Manual of P r o c e d u r e .
"The t e r m p r o p e r hood i s construed to m e a n a hood which will completely exclude a l l
outside visual r e f e r e n c e to the pilot on i n s t r u m e n t s y e t not unduly r e s t r i c t vision of
the safety pilot, agent, o r examiner. Sufficient visibility to p e r m i t c l e a r a n c e f o r t u r n s
in e i t h e r direction, a s well a s adequate f o r w a r d visibility i s r e q u i r e d
127
Flight Rules) voice p r o c e d u r e s , orientation
p r o c e d u r e s , and the u s e of i n s t r u m e n t facil-
i t i e s , and maintained p r e c i s e c o n t r o l of t h e
a i r c r a f t solely by r e f e r e n c e t o i n s t r u m e n t s
in t h e a i r c r a f t . The i n s t r u c t o r monitored
the student's p e r f o r m a n c e , i n s t r u c t e d him
in the training p h a s e s , a n d a c t e d a s the safe-
ty pilot f o r the flight.
The C e s s n a w a s u s e d f o r t h e i n s t r u -
ment flight training. The a i r c r a f t , a single-
engine high-wing monoplane, was fitted with
a cockpit i n s t r u m e n t t r a i n i n g hood t o prevent
outside vision by the t r a i n e e , t h e r e b y r e q u i r i n g
him t o fly solely by r e f e r e n c e t o i n s t r u m e n t s .
The hood c o n s i s t e d of a r u b b e r i z e d cloth ex-
tending downward f r o m the cabin top and diag-
onally a c r o s s in front of the student. The
left s i d e window w a s c o v e r e d by a louvre type
blind. 'The t r a i n e e ' s vision t o t h e r i g h t was
a l s o blocked by the diagonal blind and t h e
i n s t r u c t o r s e a t e d beside him. Construction
of t h e hood p e r m i t t e d the i n s t r u c t o r to s e e
outside the a i r c r a f t . Although h i s vision was
o b s t r u c t e d to s o m e d e g r e e he could maintain
a lookout with s o m e movement of h i s body
not normally n e c e s s a r y without the hood.
This h od was within the r e q u i r e m e n t s s p e c -
ified. Outside vision i s n e c e s s a r y because
much of the i n s t r u m e n t training i s conducted
during good weather conditions. A flight
under s u c h conditions i s c o n s i d e r e d a VFR
(Visual Flight Rules) flight and the r e s p o n -
sibility f o r s e p a r a t i o n between a i r c r a f t r e s t s
on the pilots t o s e e and avoid the o t h e r . T h e
C A A Flight Information Manual s t a t e s in p a r t ,
"When flying in VFR weather conditions ( r e -
g a r d l e s s of the type flight plan o r a i r t r a f f i c
c l e a r a n c e ) i t i s the d i r e c t responsibility of
the pilot to avoid collision with o t h e r a i r c r a f t . l 1
T e s t s w e r e conducted when weather con-
ditions and wind f a c t o r s w e r e n e a r l y identical
to those on the date of the accident. The t i m e
of t h e s e t e s t s w a s a l s o c o m p a r a b l e to t h e
t i m e of the accident. A DC-3 w a s flown i n
conformity t o the s a m e configuration u s e d by
the DC-3 flight in question, based on the in-
formation given by i t s c r e w and in conjunction
with the observations given by the n u m e r o u s
eyewitnesses. A C e s s n a w a s flown in conformity
...
.I1
128 ICAO C i r c u l a r
t o the final a p p r o a c h portion of the s t a n d a r d
low frequency r a d i o r a n g e a p p r o a c h inbound t o
the station a n d a t s p e e d s n o r m a l f o r that a i r -
c r a f t . An identical i n s t r u m e n t training hood
was u s e d on the C e s s n a . The flights w e r e a l s o
t i m e d s o that t h e i r flight paths i n t e r s e c t e d a t
the position in s p a c e approximately w h e r e the
DC-3 and the C e s s n a collided. The t e s t a i r -
c r a f t u s e d only m i n i m u m s a f e altitude s e p a r a -
tion to k e e p that v a r i a b l e t o t h e s m a l l e s t effect.
The p u r p o s e of t h e s e flight t e s t s w a s to obtain,
a s a c c u r a t e l y as p o s s i b l e , a r e c o n s t r u c t i o n of
the flight paths of the a c c i d e n t a i r c r a f t and to
l e a r n when, how long, a n d i n what r e l a t i v e po-
s i t i o n s e a c h a i r c r a f t was visible to t h e c r e w of
the o t h e r . B o a r d p e r s o n n e l w e r e p r e s e n t on
e a c h a i r c r a f t a s o b s e r v e r s . During the t e s t s
other B o a r d p e r s o n n e l watched f r o m the c o n t r o l
tower to l e a r n whether o r not the a i r c r a f t could
be s e e n f r o m t h e r e and if s o what difficulties
w e r e e x p e r i e n c e d i n locating and following t h e m
visually.
During the t e s t s t h e C e s s n a was f i r s t
s e e n f r o m the DC-3 by t h e pilot s e a t e d i n the
left s e a t . T h i s o c c u r r e d when the DC-3 was
about 23 seconds f r o m the a p p r o x i m a t e colli-
sion position and while i t was making t h e left
climbing t u r n through about 300 d e g r e e s mag-
netic. T h e r e was then approximately one m i l e
s e p a r a t i o n between the two a i r c r a f t . The C e s s -
n a r e m a i n e d visible t o t h i s pilot through the left
f r o n t windshield panel f o r 17 s e c o n d s , during
which t i m e the C e s s n a moved f r o m the left cen-
t e r of t h i s windshield toward the bottom edge.
It d i s a p p e a r e d f r o m view a t the bottom of the
windshield panel n e a r the c e n t e r post which
divided the e n t i r e windshield.
The t e s t s d i s c l o s e d that the B o a r d ob-
s e r v e r i n the r i g h t s e a t of t h e DC-3 f i r s t ob-
s e r v e d the C e s s n a during the s a m e left climbing
turn about 16 seconds f r o m t h e collision posi-
tion. The C e s s n a was then e s t i m a t e d t o be
about 3 500 f e e t away. The C e s s n a r e m a i n e d
visible t o t h i s o b s e r v e r through the right f r o n t
windshield panel f o r about 13 seconds, a t the
end of which t i m e the C e s s n a was e s t i m a t e d t o
b e about 600 f e e t f r o m the DC-3. During t h i s
t i m e the C e s s n a moved f r o m the lower left cen-
t e r of the windshield panel diagonally toward
i t s bottom edge, continuing until it d i s a p p e a r e d
below the edge n e a r the c e n t e r of the windshield
panel.
F r o m the C e s s n a , with the i n s t r u m e n t
hood in place, t h e r e was no o ~ ~ p c . r t u n i during
ty
the t e s t s f o r the pilot in the left s e a t to s e e the
DC-3. F r o m the o b s e r v e r ' s o r . n s t r u c t o r 4 s
s e a t the DC-3 could be seen ft,r L 9 serozids;
however, in o r d e r t o do s o i t was n e c e s s a r y
f o r that pilot t o l e a n f o r w a r d enough t o s e e
along the f r o n t plane of t h e hood component
i n s t a l l e d in f r o n t of the trainee-pilot s e a t . I t
was testified that o b s e r v e r - p i l o t s always a s -
s u m e d t h i s position. During t h e t i m e the DC-3
was visible i t m o v e d f r o m alongside the c o m -
p a s s a c r o s s the lower c e n t e r of t h e windshield
p a r a l l e l t o the g l a r e s h i e l d toward the left door
post, w h e r e i t d i s a p p e a r e d . The CAB o b s e r v e r
s a i d t h a t a t no t i m e while observing t h e DC-3
did i t a p p e a r to be on a collision c o u r s e with
his aircraft.
All the p a r t i c i p a n t s s a i d that, through-
out t h e s e r i e s of s i x flight t e s t s , the position
of the sun did not c a u s e g l a r e . E a c h s t a t e d
that knowing in advance t h e position of the
o t h e r a i r c r a f t was of m a t e r i a l a s s i s t a n c e in
sighting i t when they did.
During t h e s e t e s t s t h e t i m e was a l m o s t
identical when each a i r c r a f t w a s f i r s t sighted
by the o b s e r v e r in the o t h e r . Repeated t e s t
flights did not i m p r o v e the ability of the pilots
t o l o c a t e the o t h e r a i r c r a f t m o r e quickly. The
p a r t i c i p a n t s w e r e i m p r e s s e d with the difficul-
t i e s i n seeing e a c h other.
The o b s e r v e r i n the tower s t a t e d that
f r o m that position the DC-3 was c l e a r l y visible
and could be e a s i l y located during the e n t i r e
s e r i e s of flight t e s t s . The C e s s n a beyond t h r e e
m i l e s was e x t r e m e l y h a r d to s e e a n d follow
while i t was proceeding e i t h e r d i r e c t l y toward
o r away f r o m the r a n g e station. When the
C e s s n a was proceeding inbound i t f i r s t a p p e a r -
e d t o b e s o s m a l l a n d f a r away that i t s e e m e d
unlikely that both i t a n d the DC-3 would a r r i v e
a t the collision point a t the s a m e t i m e . I t was
only during the l a s t few seconds p r i o r t o a r r i v -
a l o v e r the collision point t h a t the C e s s n a ap-
p e a r e d to be i n c l o s e proximity to the DC-3.
Nearly a l l e y e w i t n e s s e s to the collision
a g r e e d that the w e a t h e r was c l e a r and that v i s i -
bility was good in a l l directions. T h o s e b e s t
positioned t o o b s e r v e the a i r c r a f t s t a t e d that
t h e DC-3 a p p e a r e d to b e heading south o r south-
southwest. Witnesses who s a w the C e s s n a s a w
i t only a few seconds before impact. They s a i d
it a p p e a r e d to be flying southeast just b e f o r e
the accident and a l s o that the collision did not
s e e m i m m i n e n t until a few seconds before i t
o c c u r r e d . O t h e r s s t a t e d that even then t h e r e
a p p e a r e d to be v e r t i c a l s e p a r a t i o n between the
a i r c r a f t . None s a w e i t h e r a i r c r a f t t a k e eva-
s i v e action.
 ICAO C i r c u l a r
The weather r e c o r d e d a few minutes after
the accident was: c l e a r ; visibility 10 m i l e s ;
wind east-northeast 10 knots.
Considering all the available evidence i t
is probable that the Cessna pilots h e a r d the
tower c l e a r them for a simulated low frequency
range approach, including the instruction to
r e p o r t on the procedure t u r n inbound. It i s
believed that t h i s was h e a r d on 119.1 m c . be-
c a u s e the low frequency r e c e i v e r was probably
then being u s e d for navigational purposes and
would not have been available for receiving the
t o w e r on 278 kc.
The tower c o n t r o l l e r s did not r e c e i v e a
r e p o r t on the procedure t u r n f r o m the Cessna.
This i s substantiated by the lack of a r e c o r d e d
tower t r a n s m i s s i o n on 119.1 in r e s p o n s e to
such a call which would have been r e c o r d e d in
the F a i r f a x tower. Had the C e s s n a r e p o r t e d
on any other frequency, such a s 122.5, this
would have been r e c o r d e d by the Municipal tow-
e r . Since t h e r e was no r e c o r d e d r e s p o n s e f r o m
the tower o r r e c o r d e d t r a n s m i s s i o n f r o m the
a i r c r a f t , i t i s believed that the pilot of the C e s s -
na did not r e p o r t a s requested o r the t r a n s m i s -
sion, for mechanical r e a s o n s , could not be m a d e
o r did not r e a c h the tower. Although the radio
equipment of this a i r c r a f t was s e v e r e l y dam-
aged, i t i s believed that n o r m a l operation could
have been expected before impact.
Since the C e s s n a flight had been instruct-
ed to r e p o r t on the p r o c e d u r e turn, i t i s r e a s o n -
able for the tower personnel to have expected i t
to do so, thereby alerting t h e m to i t s position.
Although they did not r e c e i v e the r e p o r t , a f t e r
a reasonable t i m e both c o n t r o l l e r s attempted to
locate the C e s s n a visually but w e r e unable to do
so. Considering the distance, the head-on view
presented by the C e s s n a , and other f a c t o r s af-
fecting their ability to locate i t , the Board i s of
the opinion that i t i s not unreasonable for t h e m
to have failed to s e e it. With r e s p e c t to advi-
s o r y information, i t i s believed that the tower
personnel did not c a r r y out t h e i r full function.
Both c o n t r o l l e r s knew that the C e s s n a was con-
ducting a n i n s t r u m e n t approach and that i t could
be expected by t i m e expiration to be in the l a t t e r
portion of the procedure and would be an i m p o r -
tant t r a f f i c factor a t that time. It i s believed
that under t h e s e conditions the DC-3 c r e w should
have been advised during the touch-and-go land-
ing c l e a r a n c e that the C e s s n a was maklng a
simulated approach and might be expected a s
a traffic f a c t o r .
In determining wnether o r not e a c h a i r -
c r a f t could have been s e e n f r o m the other and
the collision thus avoided, s e v e r a l f a c t o r s
m u s t be considered. The f i r s t i s the angular
l i m i t s of cockpit vision. This factor i s the
opportunity to s e e another object afforded by
the cockpit s t r u c t u r e only. A second f a c t o r
i s visual range o r the distance that a n object
can be seen. This includes the angular s i z e
and shape of t h e object, i t s background con-
t r a s t , the d e g r e e of lighting, and apparent
motion of the object. A t h i r d factor i s the
t i m e element during which the object is within
the angular visual l i m i t s of the cockpit and
within visual range. Finally, consideration
m u s t be given to the numerous physiological
f a c t o r s affecting the human ability t o locate
and s e e an object.
The DC-3's climb-out following a touch-
and-go landing was not i n accordance with the
a i r p o r t ' s approved traffic pattern, in that a
climbing left t u r n was made instead of climb-
ing on a heading of 330 d e g r e e s magnetic until
reaching a n altitude of 2 000 feet. If the proper
pattern had been flown the DC-3 might have
p a s s e d over the collision a r e a ; however, the
a i r c r a f t ' s altitude then would have been 2 000
feet. Also, the a i r c r a f t would have been i n
level flight after reaching t h i s altitude and
making the left turn, thereby affording both
pilots a b r o a d e r field of vision. The c l e a r -
ance i s s u e d by the tower to the DC-3 to make
touch-and-go landings does not constitute a
waiver to deviate f r o m the approved t r a f f i c
pattern.
A s shown by the flight t e s t s i t i s c l e a r
that both c r e w s of the accident flights w e r e af-
forded the opportunity to s e e the o t h e r ' s a i r -
c r a f t and although the t i m e element during which
this opportunity existed was not long, i t was
adequate. It i s recognized that the t i m e ele-
m e n t s a s shown by the t e s t flights w e r e obtained
by pilots who w e r e p r i m a r i l y engaged in 10-
cating the other a i r c r a f t , knew where i t should
be a t a l l t i m e s , i t s altitudes, and the t r a c t i t
w a s going to follow. This knowledge aided the
t e s t c r e w s in sighting the o t h e r a i r c r a f t .
130 ICAO C i r c u l a r

Civil A i r Regulations1) c l e a r l y s t a t e t h e t o s e e the other a i r c r a f t and acknowledges t h a t

responsibility of pilots to o b s e r v e and avoid
o t h e r a i r c r a f t . Under t h e s e regulations it was
the responsibility of both c r e w s to s e e the
o t h e r ' s a i r c r a f t and f o r the DC-3 c r e w t o take
evasive action a s i t converged on the C e s s n a
f r o m the left and r e a r . This responsibility
a l s o r e s t e d with the C e s s n a safety pilot a s the
flight e n t e r e d t h e t r a f f i c p a t t e r n a r e a i n c l o s e
proximity to t h e DC-3 a l r e a d y operating in the
pattern.
With r e g a r d to the v a r i o u s f a c t o r s af-
fecting observance of traffic, i t m u s t be recog-
nized that both flight c r e w s w e r e engaged in
flight activity which by t h e i r n a t u r e would r e -
q u i r e a diversion of attention both within and
outside the r e s p e c t i v e cockpits. The qualifica-
tion check flight would, by i t s p r e c i s e natur-e,
r e q u i r e considerable attention inside the DC-3
cockpit by both the pilot flying the a i r c r a f t and
t h e check pilot observing him. In the c a s e of
the C e s s n a only t h e i n s t r u c t o r would be a b l e t o
s e e t h e DC-3. His responsibility was c e r t a i n l y
divided between watching f o r other a i r c r a f t and
t h e duties of an i n s t r u m e n t flight i n s t r u c t o r .
The B o a r d r e c o g n i z e s the aforementioned
f a c t o r s which made i t difficult f o r t h e s e pilots
t o do s o r e q u i r e d the highest d e g r e e of vigi-
lance. However, the B o a r d expects flight
c r e w s t o e x e r c i s e the utmost vigilance i n o r d e r
t o c a r r y out t h e i r responsibility and is of t h e
opinion t h a t if both c r e w s in t h i s i n s t a n c e had
maintained a lookout c o m m e n s u r a t e with t h e i r
responsibility this accident could have been
averted.
As a r e s u l t of t h i s accident the B o a r d ' s
B u r e a u of Safety Regulation i s studying t h e
Civil Air Regulations t o s e e if any r e v i s i o n o r
modification is n e c e s s a r y .
P r o b a b l e Cause
The probable c a u s e of this accident was
the f a i l u r e of the DC-3 c r e w t o o b s e r v e the
C e s s n a and to comply with the p r e s c r i b e d a i r -
p o r t traffic p a t t e r n which r e s u l t e d in t h e i r con-
verging and overtaking it. Contributing f a c t o r s
w e r e the f a i l u r e of the tower c o n t r o l l e r to ad-
v i s e the DC-3 that t h e C e s s n a was making a
simulated i n s t r u m e n t approach and the f a i l u r e
of t h e instructor-pilot of the C e s s n a t o r e p o r t
inbound, and to s e e and avoid the o t h e r a i r -
craft.

1 ) 1'60.12 C a r e l e s s o r r e c k l e s s operation. No p e r s o n s h a l l o p e r a t e a n a i r c r a f t in a c a r e l e s s
o r r e c k l e s s manner s o a s to endanger t h e life o r p r o p e r t y of o t h e r s .

c) L a c k of vigilance by the pilot t o o b s e r v e and avoid other a i r traffic. In this r e s p e c t ,

the pilot m u s t c l e a r h i s position p r i o r t o s t a r t i n g any manoeuvre, e i t h e r on the
ground o r in flight.

1160. 14 Overtaking. An a i r c r a f t that i s being overtaken h a s the right-of-way, and the

d) overtaking a i r c r a f t , whether climbing, descending, o r in horizontal flight, s h a l l
keep out of the way of the o t h e r a i r c r a f t by a l t e r i n g i t s c o u r s e t o the right, and
no Subsequent change i n the r e l a t i v e positions of the two a i r c r a f t s h a l l absolve
t h e overtaking a i r c r a f t f r o m this obligation until i t is e n t i r e l y p a s t and c l e a r , . . I 1

1160.15 P r o x i m i t y of a i r c r a f t . No p e r s o n s h a l l o p e r a t e an a i r c r a f t in such proximity t o

other a i r c r a f t a s t o c r e a t e a collision h a z a r d . No p e r s o n s h a l l o p e r a t e an a i r c r a f t
in formation flight when p a s s e n g e r s a r e c a r r i e d f o r hire. No a i r c r a f t shall be
o p e r a t e d in formation flight except by p r e a r r a n g e m e n t between the pjlots in command
of such a i r c r a f t . "

ICAO Ref: ~ ~ / 4 1 0
 ICAO Circular 50-AN/ 45 131

PROBABLE FLIGHT PATHS OF TWA'S DC-3, N51167

AND BAKER FLYING SERVICE CESSNA 140-A, MI1580

..,.
"
.
I
.
CII....
.I..
I."

Ooto obtalned from flight test

Q-I) to Q3-0
dirtancr abng
whlch DC-5 rmr obrrrvad from Cltmm.

C18rna woe obrrrvod from D C - 3

-'&=..---'
DLIUY 1s uC1U SCA i t U l
132 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5

No. 30

P o r t of New York Authority, Bell Helicopter 47G, c r a s h e d during take-off f r o m heliport

i n New York City, N. Y., on 13 July 1955. Civil Aeronautics Board (u.S.A.)
Accident Investigation Report, F i l e No. 2-0019 r e l e a s e d 8 November 1955.

Circumstances helicopter was fitted with pontoons). When the

The a i r c r a f t landed a t 1450 h o u r s E a s t -
e r n Daylight Time a t the heliport atop the Au-
thority I s building, 111 Eighth Avenue, New
York. One passenger then boarded the helicop-
t e r to take photographs a t Staten Island of proj-
e c t s i n connection with the work of the Authori-
ty. The pilot plugged into the helicopter a n
e x t e r n a l power line and s t a r t e d the engine.
Take-off was to the southwest into a wind of
16 m. p. h. When the helicopter was about 10
feet high, i t nosed down and its r o t o r blades
s t r u c k the side of the building a t the edge of,
and immediately beyond, the heliport. It turn-
ed over and fell crashing (approximately 1515
h o u r s EDT) in a n inverted position against the
west wall and a t the edge of the heliport. The
m a i n wreckage balanced p r e c a r i o u s l y a t the
edge of the heliport a s fuel burned violently.
The f i r e burned through the webbing of both
safety b e l t s allowing both occupants to fall a
few feet to the tiled roof, both landing on their
heads. The a i r c r a f t was destroyed by impact
and ensuing f i r e , and both occupants w e r e se-
riously injured.
Investigation
- and Evidence
External power supply was used for
starting. It is communly used in,helicopter op-
e r a t i o n a s individual flights a r e often too s h o r t
t o allow recharging of the helicopter's battery.
It was a s c e r t a i n e d that the auxiliary
b a t t e r y boost cable, used for s t a r t i n g , had not
been disconnected f r o m the helicopter p r i o r to
take-off. This cable i s 32 feet, 9 inches long
s l a c k i n the e x t e r n a l power cable was used up,
the cannon plug did not pull f r e e because t h e
direction of pull was a t a l a r g e angle to the
a x i s of the plug. Consequently, the helicopter
was abruptly snubbed resulting i n the nose drop-
ping and the a i r c r a f t crashing. The pilot had
s e n s e d this d r a g only a n instant e a r l i e r and
t h e r e was no t i m e t o r e m e d y the situation. A
witness on the s t r e e t below s a w the helicopter
"quiver" before it c r a s h e d .
The heliport is 376.50 feet above m e a n
s e a level and is privately operated by the Au-
thority for i t s own use. The landing a r e a i s 40
feet by 45 feet and is surrounded by a heavy
m e s h wiring approximately 5 feet wide and a t
a n upward angle of 15 t o 20 d e g r e e s . Varking
i s conspicuous with a yellow c e n t e r c i r c l e 20
feet i n d i a m e t e r with a white b o r d e r one foot
wide and white diagonal lines one foot wide.
Investigation disclosed that f r o m May
1951, until t h i s accident, t h e r e had been over
7,500 helicopter take-offs f r o m , and landings
on, the subject heliport. All had been unevent-
ful.
G r o s s weight a t take-off was 2 097
pounds a s against a m a x i m u m allowable of
2 350 pounds. The location of the center of
gravity, which i s c r l t i c a l and e x t r e m e l y im-
portant on helicopters, was within p r e s c r i b e d
limits. A breakdown of the g r o s s weight
follows:
E m p y welght
Photographer
-- 1 170
524 pounds
IT

and c o n s i s t s of two conductors of No. 6 wire Aerial c a m e r a - 35

using a standard AN-2552-2A cannon plug. It Pilot - 140 "
i s r a t h e r l a r g e i n c r o s s sectional a r e a , strong Gas (34 gallons) - 2 10 It

i n tension, and durable. Oil (10 q u a r t s ) - 18

2 097 pounds
The external power supply receptacle
was installed on the helicopter a t the Bell fac- Weather a t the approximate time of the
t o r y , with CAA approval. It was located at s t a - accident was r e p o r t e d by the U.S. Weather
Bureau a t New York a s follows: Cumulus clouds
tion minus 12 on the left side (just r e a r of f i r e -
wall a n d pilot s e a t ) and faced ontward horizon- . 4 (approximately 5 000 feet); visibility 9 m i l e s ;
tally. relative humidity 39 p e r c e n t ; wind south 16
m , p. 11. The P o r t of New York Authority h a s
Almost ~ r n n ~ e d l a t e lafter
y take-off a a r b i t r a r i l y limited the use of their helicopters
right turn was tnade to the west toward the n e a r - s t this heliport to winds of l e s s than 30-35
by Hudson River a s d safety r n e a s u r r (the m. p. h. , o r 2 5 rzl. p.h. if gusty.
 ICAO Circular 5 0 - ~ ~ / 4 5
Maintenance on the helicopter had been
thorough and i n full compliance with a i l manu-
f a c t u r e r ' s and CAA d i r e c t i v e s . Records indi-
cated a l l periodic inspections had been meticu-
lous. The total operating time was 1 089 hours
of which 89 h o u r s had been since the l a s t 100-
hour inspection on 14 June 1955. Individual com-
ponents of the helicopter had been used well
within their specific limits. The P o r t of New
York Authority had s e t high operational stand-
a r d s for their helicopters a s well a s for the
experience levels of pilots and mechanics.
Examination of the wreckage yielded
nothing to suggest that t h e r e had been any mcbl
function of any s o r t and the pilot testified thal
there had been none.
The P o r t of New York Authority helicop-
t e r s do not c a r r y a take-off check l i s t and a r e
not r e q u i r e d to. But it is the established cus-
t o m for the pilot, and his exclusive responsi-
bility, to handle the plugging i n of the auxiliary
power cable before starting the engine and to
disconnect i t before taking off. This is s o be-
cause, a s a safety m e a s u r e , no p e r s o n s a r e
allowed on the confined a r e a of the heliport
while a helicopter i s t h e r e with r o t o r turning.
ICAO Ref: ~ ~ / i 3 6
133
In t h i s instance the pilot forgot to disconnect
the cable and s a i d s o to Board investigators.
Immediately a f t e r t h i s accident engi-
n e e r s of the P o r t of New York Authority devised
a quick and automatic r e l e a s e fitting cable plug
intended to prevent s i m i l a r accidents. This
new installation was soon applied to the Author-
ity's s i s t e r helicopter and a t a l l their landing
sites.
On the new installation the receptacle
on the helicopter f a c e s vertically down. The
plug is i n s e r t e d vertically upward. A w e ~ g l l r (1'
s e v e r a l pounds r e s t s on the s u r f a c e of the. 1 1 ~ 1 1
p o r t and is attached by a s m a l l chain wit11 I L C
inches of s l a c k to a quick-disconnect a r t r l (,I.
the plug. Should the disconnect operation t,
forgotten and the helicopter r i s e only t h t s c
inches, the weight t r i p s the a r m and the p l u g is
forcibly ejected. This type of device i s known
generically a s a mouse t r a p mechanism.
Probable Cause
The cause of this accident was the pi-
l o t ' s oversight i n not disconnecting the s t a r t i n g
cable, causing the a i r c r a f t t o c r a s h .
 Figure ia7 United Prcsslrr P h o b
Ar rtilre wreckage of a New Y a s k Port Au%orlty hoilcop%erb m g a psacasiously
oa rr ISaXVoor ledge of tS1e Part AuWkoxlity Building la M d a t t a n , extin~uisbiag
faam i a s p s a ~ c dover it; by fireman ( n a h h o w ) , The a l a r t h g cable waa not
dlaeamerled on t&e-off - I 3 July 1955,
 ICAO C i r c u l a r 5 0 - A N / ~ S
N o r t h w e s t A i r l i n e s I n c . , DC-3 a i r c x a f t , c o l l i d e d with p o w e r l i n e p o l e d u r i n g
a t t e m p t e d g o - a r o u n d a t Y a k i m a A i r p o r t , W a s h i n ~ t o n , o n 15 J u l y 1955.
C i v i l A e r q n a u t i c s B o a r d (U. S. A. ) A c c i d e n t I n v e s t i g a t i o n R e p o r t ,
F i l e No. 1-0077, r e l e a s e d 21 N o v e m b e r 1955.
Circumstances
The a i r c r a f t departed Seattle-Tacoma
A i r p o r t a t 1730 h o u r s P a c i f i c S t a n d a r d T i m e e n
r o u t e t o S p o k a n e , Washington, with a s c h e d u l e d
s t o p a t Y a k i m a , o n a n IFR ( I n s t r u m e n t F l i g h t
R u l e s ) flight p l a n v i a G r e e n A i r w a y 10 a t 9 000
f e e t c r u i s i n g a l t i t u d e , c a r r y i n g 12 p a s s e n g e r s
a n d a c r e w of 3. At 1738 t h e I F R f l l g h t p l a n w a s
c a n c e l l e d a n d r e f l l e d DVFK (Defenc-. V i s u a l
F l i g h t R u l e s ) d i r e c t t o Y a k i ~ r ~ aA. t 1805 t h e
f l i g h t w a s a d v i s e d by Y a k i m a of s t o r m a c t i v i t y
s o u t h of t h e Y a k i m a A i r p o r t . A s a r e s u l t t h e
f l i g h t c h a n g e d a t 1809 t o t h e Y a k i m a C o n t r o l
Tower frequency and was cleared for a n ap-
p r o a c h t o Runway 22. When o n b a s e l e g the tow-
e r a d v i s e d t h a t t h e wind w a s s o u t h 10 k n o t s a n d
t h e f l i g h t w a s t h e n c l e a r e d f o r a p p r o a c h t o Run-
way 16 a n d a l t e r e d i t s f l i g h t p a t h a c c o r d i n g l y .
At 1819, o n e m i n u t e o u t on f i n a l a p p r o a c h , t h e
f l i g h t w a s a d v i s e d of a 13 knot s o u t h wind a n d
c l e a r e d t o l a n d . T h e z1:cratt t o u c h e d down i n
t h e f i r s t q u a r t e r of the w e t r u n w a y , r o l l e d 2 000
feet and due t o no braking action the captain
s t a r t e d a g o - a r o u n d , 3/4 of t h e way d o w n t h e
r u n w a y . F r o m a low a l t i t u d e i t s e t t l e d t o t h e
g r o u n d 110 f e e t beyond t h e e n d of t h e r u n w a y ,
r o l l e d 219 f e e t a n d a g a i n b e c a m e a i r b o r n e . Fif-
ty nine f e e t beyond t h i s point t h e r i g h t wing
s t r u c k a p o w e r l i n e p o l e (15 f e e t a b o v e t h e g r o u n d )
a n d t h e a i r c r a f t c o n t i n u e d t o fly j u s t a b o v e t h e
g r o u n d f o r a half m i l e o v e r a p a s t u r e , c a m e i n
c o n t a c t with a 10 foot t r e e , t o u c h e d down 55 f e e t
f u r t h e r o n a n d r o l l e d 575 f e e t t o a b r a k e d s t o p .
No one w a s i n j u r e d but t h e a i r c r a f t w a s s u b s t a n -
tially damaged.
Investigation and Evidence
T h e c h a n g e f r o m the a p p r o a c h t o Runway
22 t o Runway 16 w a s m a d e while t h e flight w a s
f a r enough n o r t h of the a i r p o r t t o p e r m i t p r o p e r
r u n w a y a l i g n m e n t . W i t n e s s e s s t a t e d t h a t the
a i r c r a f t ' s a p p r o a c h a p p e d r e d to be a t a n o r m a l
a l t i t u d e but f a s t e r t h a n u s u a l . T h e r u n w a y w a s
c o v e r e d by . 0 8 i n c h e s of r a i n a t the t l m e of
landing. T h e c a p t a i n s t a t e d t h a t t h e touchdown
w a s m a d e a t a n i n d i c a t e d a i r s p e e d of 70 k n o t s
d p p r o x l m a t e l y 1 000 f e e t f r o m t h e a p p r o a c h e n d
of t h e r u n w a y a n d the b r a k e s w e r e a p p l ~ e d
135
r e p e a t e d l y with n o b r a k i n g e f f e c t . He s a i d t h a t
t h e r e w a s a "hydroplaning" e f f e c t c a u s e d by t h e
water o n the runway. Hydraulic p r e s s u r e w a s
n o r m a l and b r a k e pedal p r e s s u r e felt s a t i s f a c -
tory. Flaps were retracted immediately dtter
touchdown a n d d u r i n g t h e f i r s t p o r t i o n of t h e
larldi~lgroll the t o w e r c l e d r e d t h e a i r c r a f t t o
the r d r n p . 'The c a p t a i n a d v i s e d t h e f i r s t officc I
of no b r a k i n g e f f e c t , a d v a n c e d t h e t h r o t t l e s t o
take-off p o w e r a n d s t a r t e d a g o - a r o u n d . T h e
a i r c r a f t b e c a m e a i r b o r n e a t 70 k n o t s i n d i c a t e d
a i r s p e e d a n d as the a i r c r a f t p a s s e d t h e s o u t h
e n d of the r u n w a y a t a n a l t i t u d e of 25 f e e t a n d
a n i n d i c a t e d a i r s p e e d of 7 8 k n o t s t h e c a p t a i n
o r d e r e d " g e a r up". T h e f i r s t o f f i c e r d i d not
r a i s e t h e g e a r but p u l l e d b o t h t h r o t t l e s b a c k t o
the closed position. The captain then lowered
the nose t o hold a i r speed and re-applied full
t h r o t t l e s . H e d i d not l a n d i m m e d i a t e l y a f t e r
s t r i k i n g t h e p o w e r l i n e p o l e b e c a u s e of n u m e r -
ous cattle in the pasture.
Touchdown o n t h e i i r s t q u a r t e r of a w e t
r u n w a y wlth n o r e s u l t i n g b r a k i n g a c t i o n c r e a t e d
a d e f i n i t e p o s s i b i l i t y of o v e r r u n , t h e r e f o r e , t h e
captain's decision t o go around a p p e a r s to be
p r o p e r . He h a d m a d e p r e v l o u s g o - a r o u n d 5 o n
Runway 16 d u r i n g h i s t w e l v e y e a r s of piloting
for Northwest A i r l i n e s and t h e r e is no r e a s o n
to d o u b t t h a t t h i s one would n o t h a v e b i e n s u c -
c e s s f u l h a d i t not b e e n f o r t h e u n e x p e c t e d p o w e r
i n t e r r u p t i o n c a u s e d by t h e f i r s t o f f i c e r ' s a c t i o n
of c l o s i n g both t h r o t t l e s i n s t e a d of r e t r a c t i n g
t h e l a n d ~ n gg e a r a s o r d e r e d by t h e c a p t a i n . T h e
c a p t a l n s t a t e d t h a t t h e a p p r o a c h t o Runway 16
w a s o v e r high t r e e s a n d p o w e r l i n e s a n d n e c e s -
sitated a slightly higher than n o r m a l approach.
He f u r t h e r t e s t i f i e d t h a t a l t h o u g h t h e 70-knot
a i r s p e e d was lower than d e s i r e d for the s t a r t
of a g o - a r o u n d t h e r e w d s no d i f f i c u l t y , a n d h e
expected none, until the t h r o t t l e s w e r e c l o s e d
a t 78 k n o t s a i r s p e e d when h e o r d e r e d " g e a r up!'
The 'first officer testified that he was
not a d v i s e d of t h e g o - a r o u n d a n d t h a t t h e o r d e r
f o r g e a r up w a s t h e only thinp, s a i d b y t h e
c a p t a i n a f t e r p o w e r w a s a p p l i e d a n d t h e go-
a r o u n d s t a r t e d . I n a c c o u n t i n g f o r h i s a c t i o n of
pulling the t h r o t t l e s b a c k h i s testimony was:
"At t h e t i m e t h e c o m m d n d w a s g i v e n 1 w a s
136 ICAO Circular 5 0 - ~ ~ / 4 5
/

expecting a n o r d e r to reduce power and inas-
much a s i t looked like a c r a s h was inevitable -
when the o r d e r c a m e , I moved t h e m by sponta-
neous action. " The f i r s t officer's left hand was
resting on the control pedestal but not touching
the throttles a s the go-around s t a r t e d . He
further stated that he estimated the a i r c r a f t ' s
altitude ten feet or m o r e above the ground when
near the end of the runway and a t that time he
was waiting for the captain's o r d e r to reduce
power and cut switches.
was over the field for not m o r e than ten min-
utes. Maximum gusts of 40 knots were reported
during the s t o r m and no windshift noted. The
U.S. Weather Bureau a t Yakima A i r p o r t r e c o r d -
ed . 0 8 inch precipitation during the s t o r m .
T h e r e was no failure o r malfunctioning
of the a i r c r a f t o r i t s components p r i o r t o s t r i k -
ing the pole.
Probable Cause

The s t o r m that passed over the Yakima The probable cause of this accident was
Airport shortly before the flight landed t r a - the copilot's action in closing the throttles*which
velled f r o m the southwest t o the northeast and r e s u l t e d in i t s striking a powerline pole.

* The power interruption caused the a i r c r a f t to momentarily settle to the ground,

ICAO Ref: ~ ~ / 4 0 1
 ICAO C i r c u l a r 5 0 - ~ N / 4 5 137

No. 32

Braniff A i r w a y s , Inc. , Convair 340 a i r c r a f t ,

c r a s h e d a t Midway A l r p o r t , Chicago, Illinois, o n 17 July 1955.
A e r o n a u t i c s Board (U. S. A. ) Accident Investigation R e p o r t No, SA-308,
F i l e No. 1-0081. R e l e a s e d 15 November 1955. -
Circumstances Investigation and Evidence

The flight d e p a r t e d D a l l a s , T e x a s on
s c h e d u l e a t 0100 h o u r s C e n t r a l S t a n d a r d T i m e en
route to Chicago, Illinois, with i n t e r m e d i a t e
s t o p s a t Oklahoma City, Oklahoma; Wichita,
K a n s a s ; and K a n s a s City, M i s s o u r i , c a r r y i n g
40 p a s s e n g e r s and 3 c r e w m e m b e r s . Fog w a s
f o r e c a s t f o r the Chicago a r e a and the visibility
was expected to be r e s t r i c t e d t o possibly one-
half m i l e , on a r r i v a l . The flight s e g m e n t s b e -
tween Dallas and Wichita w e r e uneventful; how-
e v e r , while s t a r t i n g the No, 1 (left) engine a t
Wichita p r i o r to d e p a r t u r e a s m a l l c a r b u r e t o r
intake manifold f l r e o c c u r r e d . T h l s was i m m e -
dlately e x t ~ n g u i s h e dand the fllght p r o c e e d e d to
K a n s a s City where i t landed a t 0416. At 0435
the a i r c r a f t d e p a r t e d K a n s a s City in a c c o r d a n c e
with a VFR (Vlsual Flight ~ u l e s flight ) plan. It
cllrnbed t o 15 000 f e e t mean s e a l e v e l and a t 0519
r e q u e s t e d and r e c e i v e d an IFR ( I n s t r u m e n t Flight
Rules) flight plan f o r the r e r n a l n d e r of the t r i p .
At 0547 A i r Route T r a f f i c Control c l e a r e d t h e
flight a s follows: "ATC c l e a r s Braniff 560 to the
Naplerville Omni via P e o r i a , Victor 116 o v e r
Jollet, m a i i t a i n a t l e a s t 1 000 on top, tops r e -
ported 2 000 mean s e a l e v e l , contact Chlcago
C e n t e r on 118.9 mc. pnssing P e o r i a . Chlcdgo
ARTC b r o a d c a s t a s p e c i a l weather o b s e r v a t i o n
a t 0556 which w a s : "Thin o b s c u r a t , ~ o n ,v i s l b l l i t y
one-half m i l e . " The flight wds a s k e d whether
~ t could l a n d with one-half rnlle v i s i t i l ~ t yand
1 000 f e e t o b s c u r a t i o n and i t r e p l i e d that i t could.
The c r e w r e p o r t e d o v e r Napierville a t 0618 and
the a i r c r a f t was r a d a r v e c t o r e d by Approach
Control to the o u t e r m a r k e r f o r an ILS ( I n s t r u -
ment Landing S y s t e m ) a p p r o a c h t o Runway 13R
f o r landing. At 0624 the a ~ r c r a f hlt t a comrner-
cia1 s i g n , c r a s h e d through the a l r p o r t boundary
fence and stopped i n v e r t e d on the a l r p o r t . T M O
c r e w m e m b e r s and 20 p a s s e n g e r s r e c e i v e d f a t a l
i n j u r i e s , one c r e w m e m b e r and 11 p a s s e n g e r s
s u s t a i n e d s e r i o u s ~ n j u r l e sand t h e remaining 9
p a s s e n g e r s r e c e i v e d minor o r no i n j u r i e s . The
a i r c r a f t was d e m o l i s h e d by l m p a c t and f i r e .
The w e a t h e r conditions r e p o r t e d a t the
t r m e of the a c c l d e n t w e r e : P a r t i a l o b s c u r a t i o n ;
v ~ s i b i l i t yone-half mile, fog, and s m o k e : s e a
l e v e l p r e s s u r e 1014. 2; t e m p e r a t u r e 71; dewpolnt
68; wind south 6 ; a l t i m e t e r 29.94; r e m a r k s ,
fog .3.
The c o m m e r c ~ a lsign t h a t w a s s t r u c k
was located on the n o r t h e a s t c o r n e r of the in-
t e r s e c t l o n between 55th S t r e e t and C e n t r a l
Avenue w h e r e they bound the n o r t h w e s t c o r n e r
of the C h ~ c a g oMidway A i r p o r t . T h e s i g n w a s
mounted n e a r the top of a s t e e l post 11 i n c h e s
in d l a m e t e r and 18 f e e t , 2 i n c h e s high. The
s i g n w a s located a p p r o x i m a t e l y 82 f e e t f r o m
the n e a r e s t a i r p o r t boundary f e n c e a n d 1 000
f e e t f r o m the t h r e s h o l d l i g h t s of Runway 13R.
Relatlve to the ILS glide path and l o c a l ~ z e r
c o u r s e c e n t e r l l n e s , the t o p of the s i g n w a s
about 84 f e e t below and 122 f e e t left, respective-
ly. The height of the s l g n a t i t s location w a s
a l s o a p p r o x i m a t e l y 12 f e e t l o w e r than the allow-
a b l e height a s d e t e r m i n e d by t h e o b s t r u c t i o n
clearance criteria.* The glide path i n t e r s e c t s
the runway 1 600 feet p a s t t h e slgn. A s i n g l e
r o w of r e d high i n t e n s i t y a p p r o a c h lights a r e
i n s t a l l e d on the left s i d e of the runway c e n t e r
l ~ n eand extend 1 300 f e e t outward into the ap-
proach a r e a . These lights slope gradually
higher toward t h e o u t w a r d end and o p p o s i t e
t h e s i g n a r e n e a r l y i t s height.
The rlght wlug of the a i r c r a f t s t r u c k the
s i g n about 18 Inches below the top. I m p a c t
m a r k s showed that this wing w a s down &bout
11 1/2 d e g r e e s a t t h l s i n s t a n t and the a i r c r a f t
was on a magnetic heading of a p p r o x i m a t e l y 140
d e g r e e s . l h e irnpact c a u s e d f a i l u r e of i n t e g r a l
wlng s t r u c t u r e just o u t s l d e of i t s engine n a c e l l e
a n d the wing quickly s e p a r a t e d upward and r e a r -
w a r d lnto the r i g h t h o r i z o n t a l s t a b i l i z e r . The

* In the e s t a b l i s h m e n t of ~ n s t r u n l e n ta p p r o a c h p r o c e d u r e s a s outlined in the ANC ( A i r F o r c e -

Navy-Clvil) Manual, c r ~ t e r l ahave b r e n developed u l t h r e s p e c t to o b s t r u c t i o n c l e a r a n c e be-
tween Objects on the s u r f ' i c a and tlic t l ~ g h tpatli of the a l r s r a i t . In t h e c a s e of ILS p r o c e d u r e s
the nllnlrnunl cleardncc, In icct i b a i u n c t i ~ , nof the d l s t , i n ~ eoutward f r o l n tile glide path unit.
In o r d e r to adticre to tile o t ~ s rrictlor~
t c riter1.1 the r i [ ~ , c t ~ vlt.nt;th
r of t h e runway may b e rc?duced-
138 ICAO C i r c u l a r 5 0 - ~ N / 4 5
I

a i r c r a f t then r o l l e d p r o g r e s s i v e l y to the r i g h t The r a d i o and ILS r e c e i v e r s w e r e d a m -

a s l t c r a s h e d through the f e n ~ eand s t r u c k
s e v e r a l a p p r o a c h light i n s t a l l a t i o n s . N e a r l y
i n v e r t e d , the a i r c r a f t s l i d through r a l s e d con-
c r e t e runway identification m a r k e r s onto the
north-south taxiway w h e r e i t stopped i n v e r t e d
on a magnetic heading of 290 d e g r e e s . F i r e
b r o k e out during t h i s t i m e and r a p i d l y increased
in intensity until i t was quickly extinguished by
a i r p o r t f i r e m e n who r e a c h e d t h e s c e n e l e s s than
a minute a f t e r the accident.
aged but capable of being t e s t e d wlthout signif-
i c a n t a l t e r a t i o n . T e s t r e s u l t s showed that
t h i s equipment o p e r a t e d within allowable t o l e r -
a n c e s and indicated n o r m a l o p e r a t i o n could
have b e e n expected b e f o r e i m p a c t . P o s i t i v e
evidence r e v e a l e d t h a t t h i s equipment w a s prop-
e r l y tuned to the Chicago ILS f a c i l i t i e s . T h e
a s s o c i a t e d cockplt i n d i c a t o r s and flight l n s t r u -
m e n t s w e r e s o s e v e r e l y d a m a g e d that t h e l r
i n d i c a t ~ o n scould not be d e t e r m i n e d .

Impact f o r c e s with the sign, ground, light

i n s t a l l a t i o n s , and runway m a r k e r s w e r e s e v e r e .
They mutilated the n o s e s e c t i o n of the a i r c r a f t ,
c a u s e d extensive d a m a g e to the f u s e l a g e , and
t o r e off the empennage. In s e v e r a l a r e a s the
top and bottom of the p a s s e n g e r c a b ~ nw e r e
c r u s h e d c l o s e t o g e t h e r , preventing s e v e r a l p a s -
s e n g e r s f r o m escaping until f r e e d by the efficient
e f f o r t s of the e m e r g e n c y p e r s o n n e l .
~h~ investigation disclosed that the land-
ing g e a r was down and the flaps w e r e extended
equally about 15 degrees when the accident oc-
c u r r e d . Complete and e x h a u s t i v e examination
of t h e s e v e r e l y damaged a i r c r a f t s t r u c t u r e failed
t o d i s c l o s e evidence of f a t i g u e c r a c k l n g , strut-
tural f a i l u r e , o r control malfunction prior to
impact.
The left engine was f r e e of i m p a c t o r f l r e
d a m a g e . I t s combustion c h a m b e r s , 011 and fuel
s c r e e n s d i s c l o s e d no evidence of malfunction o r
f a ~ l u r e . The undamaged condition of the englne
p e r m i t t e d i t to be functionally t e s t e d without
significantalteration o r r e p a i r . The r e s u l t s of
the t e s t s indicated n o r m a l o p e r a t i o n .
The r l g h t engine was s e p a r a t e d f r o m ~ t s attempting to induce rnalfunctioning of the s y s -
n a c e l l e and extensively damaged. I t s p r o p e l l e r
shaft, nose c a s e , and f r o n t a c c e s s o r y c a s e w e r e
s e p a r a t e d f r o m t h e engine n e a r the f o r w a r d
s u p p o r t plate. D i s a s s e m b l y of the englne and
subsequent examination did not d l s c l o s e e v ~ d e n c e
of o p e r a t i n g d i s t r e s s , malfunction, o r f a i l u r e
b e f o r e t h e initial i m p a c t . A r e a s of f i r e d a m a g e
w e r e c l e a r l y t h o s e c a u s e d by f i r e following i m -
pact.
T h e r e w e r e two m o d e l s of the Bendix
o m n i - m a g i n d i c a t o r s i n s t a l l e d i n the a i r c r a f t .
The model i n s t a l l e d o n the c a p t a i n ' s panel w a s
an bIN97-G-1 and i n c o r p o r a t e d an c. .panded
l o c a l i z e r range f e a t u r e . The f i r s t o l f i c e r 1s
i n d i c a t o r was a n MN97-B and did not have t h e
expanded r a n g e . The I n s t r u m e n t s a r e designed
to indlcate to t h e pilots the position of the a i r -
c r a f t wlth r e s p e c t t o the ILS g l i d e path and
l o c a l i z e r c o u r s e d u r i n g a n ILS a p p r o a c h . Bench
and flight t e s t s w e r e conducted to d e t e r m i n e
whether o r not c o u r s e d e f l e c t i o n s w e r e d i f f e r e n t
between the two that
the the f l l g h t ~as indicated
by r a d a r , including i t s positlon a t i n i t i a l i m p a c t ,
the indications of both i n s t r u m e n t s would have
b e e n a l l k e and the deflection of t h e captain's
i n s t r u m e n t would not be withln the a r e a affected
the
P e r t i n e n t ground r a d i o and navigation
f a c i l i t i e s w e r e checked ~ m m e d i a t e l yfollowing
the accident and a l l w e r e o p e r a t i n g norrrially.
During the investigation the possibility of in-
t e r f e r e n c e affecting the p e r f o r m , ~ n c eof the ILS
components was c o n s i d e r e d . T e s t s w e r e made
tern by i n t e r f e r e n c e but t h e s e f a i l e d to produce
any significant effect on it. Lighting f a c i l i t i e s
f o r the a p p r o a c h arid landing o n 13R w e r e on and
s e t next t o the highest intensity, the positlon
nlost commonly d e s i r e d during IFR conditions.
C o m m e r c i a l lights and s t r e e t lights below the
dpproach zone had b e e n t u r n e d off a t daylight
and w e r e off a t the tirne of the accident.

T h e s h i m p l a t e s of t h e l e f t and rlght p r o - Before thv a p p r o a c h w a s s t a r t e d positive

p e l l e r s b o r e i m p a c t m a r k i n g s which indicated
that both p r o p e l l e r s w e r e in positive pitch and
positioned about 38 d e g r e e s . M e a s u r e m e n t s of
the p r o p e l l e r g o v e r n o r s p e e d e r s p r i n g r a c k s
showed that g o v e r n o r s of both p r o p e l l e r s w e r e
s e t f o r about 2 400 engine r . p. m. This evldence
indicated that both engines w e r e developing n e a r -
ly equal power a t i m p a c t and the amount was
n o r m a l f o r the a i r c r a f t during t h e l a t t e r portion
of the approach.
r a d i o and r a d a r contact was e s t a b l i s h e d and a t
t h i s t i m e the flight was given t h l~a t e s t w e a t h e r
information and a l t i m e t e r s e t t i n g .
The r a d a r a d v i s o r i e s and t e s t i m o n y of
the r a d a r c o n t r o l l e r r e v e a l e d that the flight
was Initially v e c t o r e d onto the ILS c o u r s e a n d
w a s p r o p e r l y a l ~ g n e dwlth i t b e f o r e reaching
the o u t e r m a r k e r (located 5 . 8 s t a t u t e m l l e s
 ICAO Circular 5 0 - ~ ~ / 4 5
f r o m touchdown). Advisories began f lve miles
f r o m touchdown and continued periodically until
the flight was observed one-half mile out. In
each advisory until it was 1 1/2 mile f r o m
touchdown the flight was told that i t s course and
glide path w e r e good. The controller said that
his l a s t t r a n s m i s s i o n to the flight ended with it
correcting right toward on course. He stated,
in s u m m a r y , that the approach was v e r y good
and his a d v i s o r i e s were not required. He said
advisories a r e mandatory only when the flight
exceeds c e r t a i n defined tolerances relative to
the glide path and c o u r s e line which v a r y pro-
gressively commensurate with the distance f r o m
landing. He said the flight was continuously well
within these limits throughout the approach and
a t the time he discontinued the advisories.
The synoptic weather situation which exist-
ed during the t r i p and when the accident o c c u r r e d
consisted of a broad trough of low p r e s s u r e which
extended f r o m Lake E r i e through northern Indiana,
central Illinois, and Missouri. Bounding the low
p r e s s u r e on the north and south were two high
p r e s s u r e a r e a s . The s p r e a d between the temper-
a t u r e and dewpoint was narrow o v e r the Chicago
a r e a and the t e r r a i n was moist f r o m previous
rain. These f a c t o r s , together with light surface
winds, made radiation fog easily predictable for
the Chicago a r e a and i t was f o r e c a s t before the
flight originated. The fog was especially expect-
ed during the e a r l y hours of July 17.
An experienced f o r e c a s t e r stated that fog
of this type i s commonly variable in density over
relativei; s h o r t distancks e i t h e r a s a r e s u i t of
its movement o r the variable f a c t o r s producing
the fog. He a l s o stated that slow dispersion of
industrial smoke around the a i r p o r t was another
factor affecting the density of fog. As a r e s u l t
weather observations were made continuously
during the night and e a r l y morning hours. These
reflected a gradual deterioration of the visibility
until a t the time of the accident (0624 hours) it
was one-half mile in fog and smoke. Thereafter,
a t 0655, the visibility was reported to be one-
fourth mile in fog and smoke. The observations
were taken approximately 1 1/4 mile f r o m the
accident scene and they did not incorporate the
use of electronic "end-of-the-runwayu visibility
measuring equipment.
* Operations Specifications, P a r t 20, p a r . 26 (2) (ii)
Straight-in Approaches
F o r each i n c r e a s e of 100 feet above the minimum ceiling specified, a d e c r e a s e of 1/4 mile
in visibility i s authorized, until a visibility of 1/2 mile is reached.
139
Under the reported weather conditions the
flight was permitted to land. Company minima
f o r the ILS approach a r e : ceiling 300 feet, visi-
bility 3/4 milk, Applying the sliding s c a l e $
the landing was p e r m i s s i b l e with one-half
mile visibility. Accordingl?, tlie f l i g h t was
permitted to descend along the ILS glide path
to the minimum altitude and if visual contact
was established with the runway threshold o r
approach lights i t could continue to descend
and land. After visual contact h a s been e s -
tablished the landing may b e made without
f u r t h e r adherence to the landing system. If,
however, visual contact cannot be made a t
the minimum altitude the approach must be
discontinued in accordance with the m i s s e d
approach procedure.
During the investigation and public
hearing many witnesses who were located in
the immediate accident a r e a testified o r gave
statements concerning t h e i r observations.
Several h e a r d the a i r c r a f t but because of
dense fog could not s e e it until the instant it
s t r u c k the sign o r immediately t h e r e a f t e r .
These persons said the approaching sound of
the engines seemed n o r m a l , but judging by
the volume, the a i r c r a f t s e e m e d v e r y low.
The most qualified said that power was r e -
duced a few seconds before impact. One wit-
n e s s who saw the a i r c r a f t hit the sign s t a t e d
that it appeared f a i r l y level a t that instant.
Many witnesses offered important in-
formation concerning the fog and i t s density.
Many on the scene a t the time of the accident
concurred that the fog t h e r e was v e r y dcnse
and pointed out that the fog density rapidly
increased a few minutes before the accident,
then d e c r e a s e d a f t e r it. Objects only a few
hundred feet f r o m t h e m could not be seen a t
the time. Motorists stated that west of the
accident the fog was quite dense and in sev-
e r a l c a s e s they used headlights while driving.
Others approaching f r o m the e a s t said that
the fog did not hamper their drivlng but when
they reached the immediate a r e a visibility
rapidly deteriorated until i t b e c a m e extremely
140 ICAO Circular 5 0 - A ~ / 4 5
poor. An a i r c a r r i e r flight crew testified that
while taxiing on the north taxiway f r o m the
terminal to Runway 13R visibility became some-
what poorer but remained a t least one-half
mile. One crew member noted s e v e r a l drift-
ing fog patches while taxiing.
A flight captain, whose flight was behind
the subject flight and next to land, said he did
not pass the outer m a r k e r inbound but recalled
that-he was unable to s e e the a i r p o r t at any time.
He remained above the clouds and estimated
their tops to be about 1 700 feet m. s. 1. He said
that the fog appeared like the top of an overcast,
becoming a heavy haze over the airport. While
flying in the vicinity of the outer marker he
noted a few small breaks with the ground visible
through them.
Nearly all surviving passengers agreed
that the flight was smooth and involved v e r y
little time in the clouds. Approaching Chicago
the a i r c r a f t descended smoothly until it was
above a uniform cloud coverage. It made sever-
al turns and then flew relatively straight f o r
several minutes. The a i r c r a f t began to descend
again and a s it entered the clouds several pas-
sengers recalled a s e r i e s of left and right banks.
None recalled any appreciable power changes
but all agreed that the engine sound was smooth
and uninterrupted. Two passengers stated that
the descent seemed a little steep and one, a
f o r m e r pilot, said the rate of descent increased
sharply a few seconds before the accident.
Although the Board considers construction
of the type exemplified by the commercial sign
below an approach a r e a undesirable, it believes
this accident resulted primarily because of the
extremely low altitude of the flight rather than
the height and position of the sign.
Analysis of the physical evidence, testi-
mony of witnesses, and the probable flight'path
indicate the flight was well established on the
ILS in the a r e a of the outer marker. Evidence
indicates thereafter the rate of descent was well
stabilized and the greater portion of the approach
appeared to be executed in a nearly perfect man-
ner. Strict adherence to the ILS during this
time indicates that the flight was being flown
with reference to the ILS glide path and localizer
course and that the associated ground and a i r -
borne equipment were operating normally.
After passing the one-half mile f r o m
touchdown position the a i r c r a f t departed f r o m
the glide slope and descended rapidly. Consider-
ing the various factors involved this descent
I
averaged a t l e a s t 2 000 feet per minute between
the one-half mile position and the sign.
It i s believed that a s the flight approach-
ed the middle marker the pilots probably es-
tablished visual contact with the outward end
of the approach lights and proceeded visually.
This i s the normal position where visual con-
tact must be established f o r landing o r the ap-
proach must be discontinued. As near a s can
be determined it was approximately in this
position where two passengers saw roof tops
and one witness on the ground heard a reduc-
tion in power. Both observations a r e indica-
tive that visual reference was being made then.
Without doubt the accident a r e a was
engulfed in dense fog which would limit flight
visibility to near zero. It i s believed that
this was confined to a relatively small a r e a
and was unknown to the pilots o r to ground
personnel in a position to a l e r t them.
The importance of more precise and
accurate weather reporting f o r the normal
breakout a r e a of an ILS approach has resulted
in an endeavor, for s e v e r a l y e a r s , to develop
instruments to measure the conditions in this
a r e a . As a result "end-of-the-runway'' elec-
tronic equipment i s becoming available. The
U. S . Weather Bureau has obtained 20 s e t s of
end-of-the-runway instruments consisting of
a rotating beam ceilometer for ceiling meas-
urement and a transmissometer for visibility
measurement. Installation of these instruments
i s being accomplished on a priority basis with
high volume traffic airports receiving f i r s t
consideration. As a result a ceilometer has
already been installed and i s in operation a t
the Chicago Midway Airport; the transmisso-
meter has also been installed but was not yet
in operation a s of 31 October 1955. The pro-
g r a m for the installation of the balance of these
instruments a t various a i r p o r t s will continue
during this fiscal y e a r , with 45 additional s e t s
programmed for the fiscal year 1957 a s receiv-
ed f r o m the manufacturer. The Board wishes
to endorse this program and recommends that
it progress a s expeditiously a s possible.
Based upon available evidence the Board
does not believe
1) that the pilot continued below the
prescribed minimum altitude without
having had visual references, o r that
2) a s he descended visually he saw the
heavy fog before entering it.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
Although ~t canfiot be p o s i t ~ v e l ys t a t e d on
the avallaolr evidence dnd wlthout the f l r s t
o f f i c e r ' s recollection, i t i s believed that a f t e r
v i s u a l contact had been made and the a i r c r a f t
adjusted f o r landing t h e flight unexpectedly en-
countered the a r e a of fog which reduced the
flight visibility t o z e r o . During the n e c e s s a r y
t r a n s i t i o n back t o flylng the a i r c r a f t by r e f e r -
ence to i n s t r u m e n t s it 1s believed that t h e pilot
experienced m o m e n t a r y dlsorlentatlon durlng
141
which the a i r c r a f t descended m o r e r a p i d l y be-
l o r e corrective action could be raken.
-P r o b a b l e Cause
The probable c a u s e of t h l s a c c l d e n t was
m o m e n t a r y d i s o r i e n t a t i o n c a u s e d by the l o s s of
v i s u a l r e f e r e n c e d u r i n g the f i n a l vlsudl phase of
the a p p r o a c h r e s u l t i n g in an i n c r e a s e d r a t e of
d e s c e n t a t a n altitude too low to effect r e c o v e r y .
1955. V i e w looking
~ , Gonvair 340 crerrh at Midway Airport, Chicago
Braniff A i r w i ~ t y sSnc, - 1WJly
along &e appraach path; &e oiscs;aft initially struck
18 6,high I?"IIC"G~FICI), which was approximately 90 ft, from the airport
BambXarry fence. A partion of the line of C S ~ ~ ~ Q lights
L L C Bfoutaizla of &c airport
baunrlssry) are rrkrown a t (21, The Cenvlerlir was t o the left, and belaw, &r?. normal
-
approach path arsta?iad2csMd by the rrtrcroA rlXhouetb [CIJ),

Figure? 19 Aviation Crash Injury Restarcla Phata

Braniff Airwaya, Inc,, Ganverir 340 - Right aide of cockpit and forward baggage
area, The ccr-pilot auswived, Net+ irrtrrct cockpit door ( I ) ,
 ICAO Circular 5 0 - ~ N / 4 5 143

No. 33

Bristol A i r c r a f t Company, Bristol 171 Mark IV, CF-HVX,

accident a t Vancouver Airport, British Columbia, Canada,
on 19 July 1955. Report r e l e a s e d by Canadian Department of Transport,
Air Services Branch. Civil Aviation Division

Circumstances Investigation and Evidence

A t e m p o r a r y Certificat- of Airworthi-
The aircraft was being 'Ommer-
n e s s which was valid a t the time of the acci-
c i a l l ~ a pilot Okanagan Heli- dent had been issued for the aircraft. The
copters Limited. a i r c r a f t was c o r r e c t l y loaded; and the l a s t
inspection of the engine and a i r c r a f t was on
At approximately 1420 l ~ o u r sPacific
July 1955.
Standard Time the a i r c r a f t . CF-HVX was en-
gaged in ferrying injured personnel f r o m the The pilot held a valid Senior Commer-
scene of a n accident to a Royal Canadian A i r c i a l Pilot Licence and had approximately
F o r c e a i r c r a f t located off the end of Runway 6 100 hours of flying experience of which
25 a t Vancouver Airport, to the Royal Canadian ? 050 hours w e r e on helicopters.
Air F o r c e apron on the s a m e a i r p o r t .
Of s e v e r a l people who approached the
a i r c r a f t to a s s i s t i n the removal of a n a i r -
Of the l a r g e number of Royal Canadian man injured in the e a r l i e r c r a s h , the one who
Air F o r c e personnel standing along the wall of was s t r u c k by the t a i l r o t o r s e e m e d to be un-
an office a s the a i r c r a f t landed, s e v e r a l r a n a w a r e of i t s existence, and did not h e a r o r
out towards it. The pilot maintained power and did not heed the shouted warnings of bystand-
s o m e pitch to get the r o t o r blades coned to pre- e r s , o r the warning signals of the crewman.
vent the possibility of anyone walking into the
r o t o r blades. The crewman then got out of the Substantial damage was caused to the
a i r c r a f t to attempt to keep the crowd back. t a i l r o t o r blades of the helicopter.
Probable Cause
In spite of these precautions and shouts
of warning f r o m the crew and s p e c t a t o r s , one Spectators converged on the a i r c r a f t
man r a n into the tail r o t o r and w a s s t r u c k on after landing and due t o l a c k of experience of
the head sustaining injuries which resulted in helicopters a Leading A i r c r a f t s m a n r a n into
his death. the revolving tail r o t o r .

ICAO R e f : ~ ~ / 4 0 8
144 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
No. 34
C a m b r i a n Airways Limited, Dove DH 104 S e r i e s l B , G-AKSK, c r a s h e d a t
Sloden E n c l o s u r e , New F o r e s t , 1 1/2 m i l e s west of F r i t h a m , Hants., on
23 July 1955. Ministry of T r a n s p o r t and Civil Aviation (U.K.) Aviation
Accident Report No. C636
Circumstances
Before leaving Cardiff (Rhoose) A i r p o r t
the pilot filed a Visual Flight Rules flight plan
giving an elapsed t i m e of 35 minutes f o r the
flight t o Eastleigh A i r p o r t , Southampton a t a
c r u i s i n g altitude of 5 500 f e e t and then on t o
P a r i s . The a i r c r a f t took off a t 0825 h o u r s
Greenwich Mean T i m e c a r r y i n g the pilot and 6
p a s s e n g e r s . At approximately 0850 h o u r s he
called London, a s k e d f o r c l e a r a n c e t o Southamp-
ton Zone and was told to c a l l Southampton Zone.
He then acknowledged this request. Shortly af-
t e r 0850 t h e engines b e c a m e unsynchronised and
the a i r c r a f t vibrated. The port propeller stop-
ped rotating and the a i r c r a f t lost height. On
reaching 200 f e e t the p o r t engine was r e s t a r t e d
and t h e a i r c r a f t flew v e r y low over a line of high
tension cables. I t continued to fly a t 200 f e e t a t
low speed with i n c r e a s e d vibration over undu-
lating country and a f t e r climbing slightly to
c l e a r a ridge i t descended into a densely wood-
ed a r e a . When n e a r the t r e e tops i t banked to
the left and t h e port wing t i p s t r u c k a t r e e . The
a i r c r a f t then t r a v e l l e d 400 y a r d s f u r t h e r , s t r u c k
the tops of s e v e r a l t r e e s and c r a s h e d , killing
the pilot and s e r i o u s l y injuring 4 p a s s e n g e r s .
Investieation and Evidence
Inspection a t the scene of the accident
showed that the a i r c r a f t had c r a s h e d into a
dense wood a f t e r striking the tops of t a l l oak
t r e e s . The port wing t i p was the f i r s t p a r t to
become uetached and was found 400 y a r d s f r o m
t h e m a i n wreckage. The cockpit was c r u s h e d
and the p a s s e n g e r compartment had been ripped
open, The s t a r b o a r d engine had been t o r n out
of i t s mounting and was lying about 15 y a r d s
f r o m t h e fuselage. The p o r t engine r e m a i n e d
in i t s mounting. Both p r o p e l l e r s w e r e attached
t o their r e s p e c t i v e engines but only the port pro-
peller showed evidence of being under power on
impact. T h e r e was no evidence of f i r e . The
i n e r t i a switch of the f i r e extinguishing s y s t e m
had o p e r a t e d but the methyl-bromide bottles had
not d i s c h a r g e d electrically due t o disruption of
t h e e l e c t r i c a l c i r c u i t s during the c r a s h .
-
The engines w e r e salvaged and s e n t to
t h e m a n u f a c t u r e r s f o r detailed examination.
After replacing c e r t a i n components which had
been damaged in the c r a s h the p o r t engine was
mounted in a t e s t bed and given a thorough
testing. Subsequently i t was stripped f o r de-
tailed examination. The r e s u l t s of the t e s t
and s t r i p examination showed that the engine
was in sound working o r d e r .
The s t a r b o a r d engine had sustained con-
s i d e r a b l e i m p a c t damage. When dismantled i t
was found that the crankshaft had broken a t
No. 3 crankpin. T h i s f a i l u r e had o c c u r r e d
before the c r a s h a s a r e s u l t of a fatigue c r a c k
which had developed a t a plugged hole in the
r e a r web of No. 3 crankpin. Heavy s c o r i n g
on the f a c e s of the c r a n k c a s e web and c a p of
No. 1 main bearing showed that Nos. 1 and 2
cylinders continued working a f t e r the c r a n k -
shaft had failed. The crankshaft had r u n f o r
a total of 1 205 h o u r s s i n c e manufacture i n -
cluding 619 h o u r s since the l a s t overhaul when
a modification designed to prevent f a i l u r e s of
this n a t u r e was embodied.
Both p r o p e l l e r s w e r e subjected to a s t r i p
examination, including the units connected with
the s y s t e m f o r feathering the s t a r b o a r d propel-
l e r , but no evidence of any p r e - c r a s h defect
was found. The blades of both p r o p e l l e r s w e r e
i n fine pitch.
T h i s i s the second accident to a Dove
a i r c r a f t within one month in which the pilot
shut down the port engine instead of the s t a r -
board engine which had developed s e r i o u s
mechanical trouble.
In both accidents the pilots w e r e expe-
r i e n f - e d and had completed o v e r 500 h o u r s
f l y ~ r ~a gs pilot-in-command in the type. T h r e e
f a c t o r s which might possibly give r i s e to this
kind of mistake w e r e s u g g e s t e d in the r e p o r t
on the f i r s t accident (H. M.S.O. r e f . C. A. P.
133). Only one of t h e s e f a c t o r s i s , however,
common t o both accidents, namely, the com-
bined oil p r e s s u r e / t e m p e r a t u r e gauge. T h i s
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
i n s t r u m e n t i s duplicated, one f o r e a c h engine,
and n o r m a l l y mounted slde by s i d e . E a c h in-
s t r u m e n t i s m a r k e d "OIL" a t the top c e n t r e and
although annotated "LB/,-J" and "OC" r e s p e c t i v e -
ly a t t h e bottom t h e m a r k i n g of adjacent p r e s -
s u r e and t e m p e r a t u r e s c a l e s a r e not d i s s i m i l a r .
A f a l l in o i l p r e s s u r e i n the s t a r b o a r d engine
would be r e c o r d e d by the left-hand pointer of
the s t a r b o a r d gauge. It i s p o s s i b l e that a pilot
seeing the left-hand pointer of the s t a r b o a r d
gauge falling could, i n t h e s t r e s s of t h e moment,
a s s o c i a t e "left" with "port" and i n consequence
shut down the sound p o r t engine i n s t e a d of the
failing s t a r b o a r d engine.
In t h e s u b j e c t a c c i d e n t t h e pilot a p p e a r s
t o have r e a l i s e d h i s m i s t a k e and r e s t a r t e d the
ICAO R e f : ~ ~ / 4 2 4
145
p o r t engine. Unfortunately, by t h i s t i m e t h e
a i r c r a f t was down to a v e r y low altitude. E v e n
then, had t h e starboarck engine been s h u t down
and i t s p r o p e l l e r f e a t h e r e d , t h e a c c i d e n t m i g h t
have been avoided. Why t h i s w a s not done c o d d
not be d e t e r m i n e d .
Probable Cause
T h e a c c i d e n t was t h e r e s u l t of the pilot
m i s t a k e n l y shutting down t h e p o r t engine i n s t e a d
of t h e s t a r b o a r d engine i n which a s e r i o u s m e -
c h a n i c a l f a u l t h a d developed. T h i s l e d t o a
r a p i d l o s s of height a n d although t h e pilot r e -
s t a r t e d t h e p o r t engine the s t a r b o a r d engine w a s
not s h u t down.
146 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5

No. 35

E l Al, I s r a e l A i r l i n e s Ltd., Lockheed Constellation 149, 4X-AKC, was

shot down n e a r the Bulgarian-Greek b o r d e r on 27 July 1955. R e p o r t of'
C o m m i s s i o n of Inquiry, M i n i s t r y of Communications, State of I s r a e l ,
r e l e a s e d 18 August 1955

Circumstances t e m e r a t u r e a t 500 mlb. l e v e l (18 000 f e e t )

The a i r c r a f t took off a t 2015 h o u r s G r e e n -
wich Mean T i m e on 26 July f r o m London f o r
Tel-Aviv with s t o p s a t P a r i s and Vienna. On
27 J u l y it d e p a r t e d (0253 h o u r s ) Vienna with a n
e s t i m a t e d t i m e of a r r i v a l o v e r Belgrade of 0436
hours. While i n the a r e a of t h e Yugoslav-Bul-
g a r i a n b o r d e r a t a n altitude of approximately
18 000 f e e t t h e a i r c r a f t was f i r e d upon by two
Bulgarian fighters. Following two m o r e a t t a c k s
t h e a i r c r a f t broke up i n m i d - a i r a t a n altitude
of 2 000 f e e t a n d fell t o the ground i n f l a m e s a t
a point 3-1/2 k i l o m e t r e s s o u t h e a s t of the junc-
tion of t h e R i v e r s S t r u m i c a and Strumon in Bul-
g a r i a n t e r r i t o r y n e a r the Bulgarian-Greek b o r -
d e r , killing a l l 5 1 p a s s e n g e r s and 7 c r e w m e m -
bers.
Investigation and Evidence
At 0537 on 27 July Athens A i r Traffic
Control r e c e i v e d a n SOS f r o m 4X-AKC on a
frequency of 3 481 kc/s. This m e s s a g e was
r e l a y e d i m m e d i a t e l y t o Lod ATC. However,
b e f o r e s e a r c h and r e s c u e action could be taken
Athens ATC was i n f o r m e d t h a t the a i r c r a f t had
been o b s e r v e d falling in f l a m e s n e a r the Bulga-
r i a n village of T s e r b a n o v a a n d notified Lod ATC.
The weather conditions o v e r the r o u t e have a t 4 500 feet, 2/8 of Alto-Cumulus a t 9 000
been divided into t h r e e s e c t i o n s a s follows:
1. Weather on the A m b e r 10 Airway be-
tween Belgrade-Kraljevo-Skoplje and
Gevgelia-Salonika,
2. Wind direction and velocity o v e r the
above route.
3. Weather o v e r the South Bulgarian
territory.
1. Weather on A m b e r 10 between B e l g r a d e
and Kraljevo
Broken c l o l ~ d s( a v e r a g e 3/8), 3/8 of S t r a t o - i n the North and a "HIGH" p r e s s u r e a r e a i n the
Cumulus, 3/8 of Cumulus, cloudb,isa approxi-
m a t e l y 2 000 f e e t , cloudtops abcut 8 0 0 0 ~ P C - L , i r o : ~l h ~t - Y c g o s l a v - G r ~ e kb o r d e r southwards.
-1 18C . , visibility 10 lun., but hazy due t o
s u n r i s e hour.
Kraljevo-Skoplje
I n c r e a s i n g cloud amounts (6-8/8). 3-5/8
Cumulus and Strato-Cumulus, b a s e a t 4 000
feet, 3/8 of Alto-Cumulus b a s e 9 000 f e e t , but
c o n s i d e r a b l e locally i s o l a t e d build u p s of Cu-
m u l u s and Cumulonimbus reaching t o 20-25 000
f e e t with thunder, s h o w e r s , lightning, icing
and s e v e r e turbulence. S p r e a d of t h e s e devel-
oped Cu and C b f s on w e s t - e a s t e r l y belt about
80 MILES WIDE and extending a t l e a s t 100
MILES either s i d e of Airway A m b e r 10.
T h e s e clouds have been r e p o r t e d a s
"past weather" ( l a s t t h r e e h o u r s ) and a s " l a s t
hour" and " p r e s e n t weather" a t 0600 h o u r s .
The international synoptic a c t u a l weather f o r
South Yugoslavia and N o r t h e r n G r e e c e f o r the
27th a t 0500 h o u r s r e a d s : " F a i r t o cloudy,
l o c a l o v e r c a s t with thundery s h o w e r s mainly
t o north. I t
Skoplje-Salonika
Weather cloudy to f a i r , r a p i d i m p r o v e -
m e n t of l o c a l cloudy conditions. 1/8 Cumulus
feet. Visibility 10-25 km. T e m p e r a t u r e a t
18 000 f e e t Minus 1 lot.
2. Upper Wind Direction and Velocity on
Amber 10 Airway between B e l g r a d e and
Yugoslav-Greek B o r d e r
The direction of the upper wind (18 000
f e e t ) was constant f r o m 260-270° throughout
the 300 MILES s t r e t c h .
At B e l g r a d e and up t o a point about 50
m i l e s south, the velocity was a s f o r e c a s t about
20-25 knots. F r o m then on, the wind i n c r e a s e d
s h a r p l y to a xelocity of 70 knots, due to the
d e v e l o p n ~ e n tof a l a r g e "LOW" p r e s s u r e a r e a
South a t 1 3 300 f c r t lelrel, a f t e r that d e c r e a s i n g
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
I n t e r n a t i o n a l Synoptic R e p o r t f o r U p p e r
Winds
South Yugoslavia a n d N o r t h e r n G r e e c e -
t h e 27th, 0500 h o u r s
a ' 10 000 f e e t 270°/35 k n o t s
a t 18 000 f e e t 260°/70 k n o t s
Note:- Another JAT pilot f l y i n g t h e s a m e r o u t e
- a t 0900 h o u r s a t 12 500 f e e t r e p o r t e d
wind of 270°/78 k n o t s .
3. W e a t h e r o v e r South B u l e a r i n
T h e w e a t h e r w a s f i n e , t r a c e s of m e d i u m
a n d h i g h cloud. V i s i b i l i t y good. Wind a s in
previous paragraph.
Of t h e w e a t h e r a s d i s c u s s e d a b o v e t w o
f a c t o r s a r e m o s t relevant to this flight:
F i r s t l y , t h e p r e s e n c e of C u m u l o n i m b u s
c l o u d s on t h e r o u t e , a n d s e c o n d l v , t h e
s u d d e n u n p r e d i c t e d c h a n g e of the' wind
v e l o c i t y f r o m 20 t o 70 k n o t s .
T h e C o m m i s s i o n i m m e d i a t e l y o n appoint-
ment applied t o the Bulgarian Legation in Tel-
Aviv f o r v i s a s t o e n t e r B u l g a r i a i n o r d e r t o p r o -
c e e d with t h e i n v e s t i g a t i o n on t h e s p o t . F u r t h e r -
m o r e , the Bulgarian Legation w a s approached
by t h e I s r a e l F o r e i g n M i n i s t r y with t h e r e q u e s t
t h a t t h e I s r a e l C o m m i s s i o n of I n q u i r y a c t i n
c o n j u n c t i o n with t h e ~ n v e s t i ~ a t i o C ; ommittee
a p p o i n t e d by t h e B u l g a r i a n G o v e r n m e n t i n a c -
c o r d a n c e with i n t e r n a t i o n a l p r a c t i c e . T h e a n -
s w e r to the application f o r v i s a s w a s that the
m a t t e r h a d b e e n r e f e r r e d t o Sofia with t h e r e -
q u e s t t h a t v i s a s b e i s s u e d by t h e B u l g a r i a n L e g a -
tion i n A t h e n s i n o r d e r to s a v e t i m e . No a n s w e r
was received to the request to participate in a
joint i n v e s t i g a t i o n .
The Commission, immediately on a r r i v a l
at Athens, approached the Bulgarian Legation
which had not yet r e c e i v e d instructions to i s s u e
the n e c e s s a r y visas. The approach was m a d e
t h r o u g h t h e I s r a e l L e g a t i o n i n A t h e n s . T h e Bul-
g a r i a n Legation a g r e e d to endeavour t o a r r a n g e
f o r v i s a s t o b e i s s u e d a t t h e f r o n t i e r . A g a i n in
o r d e r to s a v e time, the Commission proceeded
t o a G r e e k b o r d e r v i l l a g e n a m e d K u l a , 1 4 kilo-
m e t r e s f r o m t h e s i t e of t h e w r e c k a g e , w h e r e i t
r e m a i n e d waiting f o r p e r m i s s i o n t o c r o s s i n t o
Bulgaria. During this t i m e i t interviewed and
t o o k t h e t e s t i m o n y of a n u m b e r of G r e e k eye-
w i t n e s s e s who w e r e s t a t i o n e d a t b o r d e r p o s t s .
147
T h e C o m m i s s i o n s p e n t 28 a n d 2 9 J u l y o n
the b o r d e r awaiting p e r m i s s i o n t o enter and
w a s a b l e t o o b s e r v e p o r t i o n s of t h e w r e c k a g e
a n d t h e a c t i v i t y on t h e s i t e . T h e a c t i v i t y w a s
c o n s i d e r a b l e . T r u c k s w e r e s e e n m o v i n g arourrd
in t h e a r e a a n d w r e c k a g e w a s b e i n g t r a n s p o r t e d
t o p l a c e s o u t of view.
P e r m i s s i o n was eventually g r a n t e d t o
e n t e r B u l g a r i a o n 3 0 J u l y , b u t t h e n u m b e r of
PflSOnS limited t h r e e and were
obliged to r e t u r n before sunset.
The t e a m found that
1. m a n y p a r t s of t h e a i r c r a f t h a d b e e n
removed f r o m the places where they
originally fell;
2. a m o s t t h o r o u g h s e a r c h h a d b e e n m a d e
of t h e w r e c k a g e . L i n i n g h a d b e e n
r i p p e d off a n d a l l c l o s e d s t r u c t u r e s
had been opened for examination;
3. t h e r e w e r e h o l e s of v a r i o u s c a l i b r e s
too n u m e r o u s to detail i n t h e s h o r t
t i m e available;
4. a l l t r a c e s of b o d i e s , l u g g a g e a n d p e r -
sonal belongings had been removed;
5. n e a r l y a l l c o c k p i t e q u i p m e n t , s u c h a s
radios, instruments, electrical panels,
h a d b e e n r e m o v e d a n d w e r e not a v a i l -
able f o r examination. Only one r a d i o
c o m p a s s indicator and s o m e completely
s m a s h e d r a d i o s e t s w e r e found.
Before leaving Bulgaria the t e a m r e q u e s t e d
p e r m i s s i o n t o i n t e r v i e w w i t n e s s e s who c o u l d
give f u r t h e r i n f o r m a t i o n . T h e y r e q u e s t e d p a r -
t i c u l a r l y t o s e e t h e p i l o t s of the j e t f i g h t e r s who
w e r e obviously t h e only w i t n e s s e s t o g i v e f u l l
a n d d e t a i l e d i n f o r m a t i o n a s t o what h a d h a p p e n -
ed. T h e y f u r t h e r r e q u e s t e d p e r m i s s i o n t o
i n t e r v i e w t h e C o r n m a n d i n g O f f i c e r who h a d
o r d e r e d t h e f i g h t e r s t o t a k e off a n d , i n a d d i -
t i o n , p e r s o n s a l o n g t h e f l i g h t path. T h e y a l s o
a s k e d f o r t h e r e t u r n of a i r c r a f t p a r t s t h a t h a d
been removed f r o m the site. T h e r e s p o n s e to
t h i s r e q u e s t w a s t h a t i t would b e r e f e r r e d t o
t h e a u t h o r i t i e s a t Sofia. U n f o r t u n a t e l y , no a n -
s w e r had been r e c e i v e d to t h e s e r e q u e s t s u p t o
t h e t i m e of w r i t i n g t h i s r e p o r t a n d t h e C o m m i s -
s i o n w a s o b l i g e d t o p r e p a r e i t without t h i s v i t a l
e v i d e n c e bqing a v a i l a b l e f r o m B u l g a r i a . T h e
only Bulgarian evidence is t h e official commu-
niqui. ( q u o t e d a t t h e e n d of t h i s r e p o r t ) of t h e
f i n d i n g s of t h e B u l g a r i a n I n v e s t i g a t i o n C o m m i t -
t e e which e s t a b l i s h e d beyond a n y doubt t h a t t h e
a i r c r a f t w a s a t t a c k e d a n d b r o u g h t down by
Bulgarian fighters.
148 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
The Commission next sought p e r m i s s i o n
to e n t e r Yugoslavia in o r d e r to gather evidence
there. V i s a s w e r e duly granted by t h e Yugo-
s l a v a u t h o r i t i e s a t s a l o n i k a and a t 1400 h o u r s on
2 August four m e m b e r s of the Commission
c r o s s e d the Greek-Yugoslav b o r d e r a t Gevge-
lia. The witnesses interviewed by the Corn-
m i s s i o n w e r e a l l m i l i t a r y personnel who had
been stationed a t points along the Yugoslav-
Bulgarian border. One m e m b e r of t h e Corn-
m i s s i o n visited Skoplje and Belgrade a e r o -
d r o m e s and gathered information f r o m the
Civil Aviation authorities. He a l s o interviewed
the Flight Control Officer who had been on duty
a t the t i m e the a i r c r a f t p a s s e d over Belgrade
and a JAT Airlines Captain who had flown the
Airway Amber 10 on the morning of 27 July.
Aids
- to Navigation
The a i r c r a f t r e p o r t e d o v e r B e l g r a d e a t
0433 hours. Belgrade h a s the following navi-
gational aids: Two non-dir ectional beacons
with c a l l signs BD and ZN. The a i r c r a f t u s e d
t h e BD beacon in i t s flight plan and when r e p o r t - r e l i a b l e f o r steady c o u r s e indication. T h i s
ing. Both beacons w e r e , a t t h i s t i m e and date,
s e r v i c e a b l e . The BD beacon h a s an a e r i a l out-
put of 1 500 Watt. In addition to t h e s e two bea-
cons, Belgrade h a s a VOR which was working
normally.
The next reporting point Kraljevo h a s no
navigational aid.
The reporting point a t Skoplje, where
Airway Amber 10 changes i t s direction f r o m
161° (magnetic) to 142O (magnetic), i s equipped
with a non-directional beacon with an a e r i a l out-
put of 1 200 Watt. This beacon was working
n o r m a l l y a t the t i m e of the flight. Between
Belgrade and Skoplje, a distance of 177 nauti-
c a l m i l e s , no o t h e r r a d i o a i d i s available either
on the airway o r a b e a m of it.
The reporting point a t the Yugoslav-Greek
b o r d e r i s the town of Gevgelia. T h e r e i s no
navigational facility whatever a t this point.
The next navigational aid i s a 350 Watt
non-directional beacon a t Salonika. T h e r e i s ,
t h e r e f o r e , a f u r t h e r distance of 107 nautical
m i l e s between Skoplje and Salonika without any
i n t e r m e d i a t e navigational aid. I t should be
mentioned in addition that according to informa-
tion r e c e i v e d f r o m a P a n A m e r i c a n Airways
flight using the Salonika beacon a t this t i m e ,
r e l i a b l e reception was limited to a s m a l l a r e a
over the beacon.
*
The Constellation w a s fitted with two
s e r v i c e a b l e r a d i o c o m p a s s e s (Bendix), e a c h
r a d i o c o m p a s s being an independent unit f r o m
the indicator to the loop and s e n s e a e r i a l .
T h e r e w e r e a l s o two independent VOR units
(Bendix) installed in the a i r c r a f t . T h e r e w e r e ,
in addition, 1 magnetic c o m p a s s and 1 Flux-
gate c o m p a s s . T h e s e had been swung and ad-
justed on 18 May 1955. Both pilot positions
w e r e equipped with full i n s t r u m e n t panels, in-
cluding 3 directional gyros. T h e r e w e r e a l s o
2 ILS installations with 75 M C / S M a r k e r r e -
c e i v e r s . One Radar a l t i m e t e r and a L o r a n
s e t w e r e installed a t the navigator's position.
It i s a s s u m e d that when within r a n g e of
the BD beacon and the VOR a t Belgrade, t h e s e
a i d s w e r e used. The VOR was, no doubt, help-
ful i n keeping the a i r c r a f t in the airway f o r the
f i r s t p a r t of i t s flight f r o m Belgrade towards
Skoplje. The r a n g e of the VOR should not be
c o n s i d e r e d r e l i a b l e beyond 70-80 nautical
m i l e s . T h e range of the BD beacon owing t o
t h u n d e r s t o r m s could not have been c o n s i d e r e d
applies, and even to a g r e a t e r extent, to the
Skoplje beacon which was s u r r o u n d e d by static.
The Salonika beacon due t o i t s low output and
the possibility of c o a s t a l r e f r a c t i o n would not
have been reliable. It should be noted that the
effectiveness of a l l t h r e e non-directional bea-
cons m a y have been reduced by s u n r i s e condi-
tions.
The Flight
T h e r e i s no doubt that, when t h e a i r c r a f t
r e p o r t e d o v e r Belgrade, it was, in fact, o v e r
the r e p o r t e d position. This was confirmed by
the Control Officer a t Belgrade who s t a t e d that
he had h e a r d the a i r c r a f t overhead a t the t i m e
of i t s r e p o r t . The radio facilities at Belgrade
d e s c r i b e d e a r l i e r and the a i r b o r n e equipment
available would e n s u r e t h a t the a i r c r a f t could
not be off c o u r s e a t this point.
Belgrade to Point 0510 (Vicinity Skoplje)
F r o m B e l g r a d e t h e a i r c r a f t heading would
be along the Airway Amber 10, that i s to s a y
on a magnetic c o u r s e of 161°. The winds f o r e -
c a s t f o r this p a r t of the route and used in the
flight plan were 270°/20 knots at an altitude of
18 000 feet. The altitude for which the a i r c r a f t
was 'cleared was 17 500 feet. The wind a s f o r e -
c a s t r e q u i r e d a c o r r e c t i o n of 4O to the right,
giving a heading of 165O. This was the heading
used in the flight plan. The t i m e f o r the l e g
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
Belgrade-Skoplje calculated i n the flight plan
was 44 minutes. The planned a r r i v a l over
Skoplje was, t h e r e f o r e , 0517. The a c t u a l r e -
porting t i m e over Skoplje was given a s 0510,
that i s to s a y 37 minutes elapsed between the
r e p o r t over Belgrade and the r e p o r t over
Skoplje. The wind f o r the f i r s t half of t h i s leg
was, in f a c t , a s f o r e c a s t .
Plotting the a i r c r a f t ' s position a f t e r com-
pletion of the f i r s t half (70 nautical m i l e s ) of
the leg on the b a s i s of an indicated a i r s p e e d of
200 statute m i l e s p e r hour a t an altitude of
17 500 f e e t with an outside t e m p e r a t u r e of
- 1 l°C., which gives a t r u e a i r s p e e d of 230
knots, we a r r i v e a t the point m a r k e d 0451 1/2.
(See F i g u r e 20).
F r o m this point on the winds actually
encountered w e r e 260°/70 knots. The winds
f o r e c a s t w e r e 2700/20 knots. The pilots could
not have been a w a r e of the wind i n c r e a s e and
would not, t h e r e f o r e , have m a d e any c o r r e c -
tion to t h e c o u r s e . The a i r c r a f t m u s t , t h e r e -
f o r e , have continued on the s a m e bearing a s
b e f o r e (1650) until reporting o v e r Skoplje ( a t
0510). At this t i m e the a i r c r a f t would, in fact,
have left the airway and a r r i v e d a t the point
0510. (See F i g u r e 20). The p r e m a t u r e r e p o r t
over Skoplje beacon was probably due to an
e r r o n e o u s indication of the r a d i o c o m p a s s in-
fluenced by the t h u n d e r s t o r m s which w e r e well
developed n e a r the actual flight path. I t should
a l s o be rloted that the e a s t e r l y t r e n d of the flight g r a d e by r e l i a b l e t r a c k indicating navigational
path could not have been checked by a i r to ground a i d s (VOR). They w e r e experienced pilots
observations oving t o the f a c t that the a i r c r a f t
was passing over clouds.
In the section of this r e p o r t dealing with
the weather i t was noted that f r o m Kraljevo t o
south of Skoplje t h e r e w e r e considerable build-
ups and i s o l a t e d cumulonimbus reaching g r e a t
heights with lightning, icing and s e v e r e turbu-
lence. Encountering t h e s e conditions, t h e pilots f i g h t e r s warned the a i r c r a f t t o land "in con-
would, a s a m a t t e r of o r d i n a r y a i r l i n e p r a c t i c e , f o r m i t y with established international r e g u l a -
m a k e s m a l l d e t o u r s wherever possible, to avoid tions. In spite of t h i s i t would not obey and
p a s s e n g e r discomfort. In reconstructing the
flight path i t h a s not been possible to r e f l e c t
slight v a r i a t i o n s of c o u r s e due to s u c h d e t o u r s
but these should be b o r n e in mind in evaluating
t h e a c c u r a c y of the reconstruction.
Vicinity Skoplje (Point 0510) to Vicinity
Yugoslav-Bulgarian B o r d e r (Point 0528)
Assuming they w e r e a t Skoplje beacon,
t h e pilots a t 0510 a l t e r e d c o u r s e to t h e new
heading of the airway, namely 142' c o r r e c t e d
for the f o r e c a s t winds to 146O. They s t e e r e d
t h i s c o u r s e for 18 minutes before reporting
149
o v e r the b o r d e r a t 0528. Plotting the c o u r s e
taken during the 18 minutes with allowance
for the actual wind, we a r r i v e a t t h e point
0528. (See F i g u r e 20). We conclude this was
the a i r c r a f t ' s a c t u a l position when i t r e p o r t e d
over the Yugoslav-Greek b o r d e r . I t was, in
f a c t , c l o s e to the Yugoslav-Bulgarian b o r d e r
a t a point approximately 26 nautical m i l e s n o r t h
of the G r e e k b o r d e r . Continuing on t h i s c o u r s e
for a f u r t h e r few minutes, the a i r c r a f t would
c r o s s into Bulgarian t e r r i t o r y .
The place of t h i s c r o s s i n g c o r r e s p o n d s
to the position where the Yugoslav e y e w i t n e s s e s
o b s e r v e d the a i r c r a f t .
At this stage we f e e l obliged t o r e f e r t o
the findings of the Bulgarian Investigation Com-
m i t t e e (quoted a t the end of this r e p o r t ) which
w e r e t o the effect t h a t the a i r c r a f t e n t e r e d
Bulgaria a t the town of T r n and a f t e r p e n e t r a t -
ing Bulgarian a i r s p a c e f o r 40 krns. t u r n e d
south and flew o v e r v a r i o u s Bulgarian towns.
South of t h e town of Stanke Dimitrov the plane
was i n t e r c e p t e d by two Bulgarian f i g h t e r s
which warned i t to land. Having r e g a r d to the
f a c t that the town of T r n i s on a b e a r i n g of 1350
(magnetic) f r o m B e l g r a d e and a t a distance of
147 nautical m i l e s f r o m it, s u c h a c o u r s e i s
quite unrelated to t h e pilots' flight plan o r t o
the direction in which they w e r e making. The
winds in this region w e r e a s predicted. T h e
pilots w e r e a s s i s t e d f o r 70 m i l e s out of Bel-
f a m i l i a r with t h e route. We a r e s a t i s f i e d that
they could not have flown f o r s o m e 41 m i n u t e s
on a n entirely a r b i t r a r y c o u r s e , then t u r n e d
s h a r p l y south on an e n t i r e l y new c o u r s e with-
out a p p a r e n t r e a s o n , and t h e r e a f t e r r e p o r t e d
without c o m m e n t o v e r the G r e e k b o r d e r .
It i s s t a t e d i n the above findings t h a t the
continued in i t s flight t o w a r d s the south in
trying t o escape". It i s inconceivable that an
u n a r m e d civil a i r c r a f t with an experienced
c r e w having 51 p a s s e n g e r s a b o a r d would not
obey o r d e r s adequately given by two a r m e d
f i g h t e r s . F u r t h e r , the subsequent behaviour
of t h e f i g h t e r s i s inconsistent with any p r e v i o u s
warning having been given. The f i g h t e r s at-
tacked the a i r c r a f t a second t i m e when i t had
l o s t considerable height and w a s evidently
seeking f o r a place to land. A l a s t a t t a c k w a s
c a r r i e d out at a t i m e when the c o u r s e of t h e
a i r c r a f t was northward heading f u r t h e r into
Bulgarian t e r r i t o r y ; the a i r c r a f t had a l r e a d y
150 ICAO C i r c u l a r 5 0 - ~ N / 4*5
been hit and was obviously making an approach
f o r a f o r c e d landing either in the Strumon val-
ley o r on a n abandoned a i r f i e l d f u r t h e r north.
Finally, no radio warnings on the frequency
fixed by t h e International Civil Aviation Organ-
ization f o r a i r c r a f t communication in t h i s r e -
gion w e r e i n t e r c e p t e d by e i t h e r G r e e k o r Yugo-
slav aeronautical statiolis keeping watch.
The Commission, t h e r e f o r e , a f t e r c a r e -
ful consideration cannot a c c e p t the findings on
this point a s s e t out i n the official Bulgarian
CommuniquC.
The Yugoslav w i t n e s s e s m a d e t h e i r ob-
s e r v a t i o n s f r o m points along the Yugoslav-
Bulgarian border. One of the t h r e e w i t n e s s e s
stationed a t the point m a r k e d t l A t lon F i g u r e 20
saw a l a r g e a i r c r a f t flying in a s o u t h e a s t e r l y
direction o v e r Bulgaria and two f i g h t e r s ap-
proaching i t f r o m the east. One of the f i g h t e r s
took u p a position between t h e l a r g e a i r c r a f t
and t h e Yugoslav-Bulgarian b o r d e r . The o t h e r
fighter manoeuvred around the l a r g e a i r c r a f t .
All t h r e e w i t n e s s e s a t t h e point "Aw h e a r d b u r s t s T h e s e w i t n e s s e s h e a r d a loud explosion a t t h e
of machine-gun f i r e but none of t h e m saw signs
of a hit. The two w i t n e s s e s stationed a t the
point t t B t th e a r d an a i r c r a f t t o the n o r t h e a s t of
t h e i r position and h e a r d b u r s t s of machine-gun
f i r e . They then o b s e r v e d the a i r c r a f t moving
in a s o u t h e a s t e r l y & r e c t i o n t o w a r d s the G r e e k h e a r d shots immediately before the a i r c r a f t
b o r d e r . After t h i s they h e a r d m o r e machine-
gun f i r e . The a i r c r a f t was flying in a south-
e a s t e r l y direction and was about 7 k i l o m e t r e s
distant f r o m t h e observation post when i t dis-
a p p e a r e d f r o m view. A witness stationed a t
t h e point "Ctl a l s o saw the a i r c r a f t t o the north-
e a s t of his position and o b s e r v e d i t flying to the
southeast and losing height. He h e a r d machine-
gun f i r e but did not o b s e r v e f i g h t e r s o r s m o k e
f r o m the plane when i t d i s a p p e a r e d over the
mountain m a r k e d on F i g u r e 20 with the c o - o r -
dinates 4l028*N 23004'E.
The next w i t n e s s e s t o s e e t h e a i r c r a f t
w e r e the G r e e k o b s e r v e r s along the Greek-
B u l g a r i a n border. The f i r s t group of o b s e r v e r s the point 0528 t o the mountain o v e r which i t
( 3 w i t n e s s e s ) stationed a t the point ltO" ( s e e
F i g u r e 21) s a w the a i r c r a f t approach o v e r the
mountain f r o m the northwest. When i t appeared, 6 000 f e e t high and t h e a i r c r a f t w a s d e s c r i b e d
s m o k e was coming f r o m i t s right side. Before
t h e a i r c r a f t c a m e into view one witness h e a r d
what he took t o be heavy gun f i r e and another
what he thought was thunder. Tht: a i r c r a f t was
s e e n flying southeast losing height but under
control.
South of P e t r i c i t h e a i r c r a f t startt-d to
t u r n t o w a r d s t h e northeast, heading for the
plain n o r t h of hills 224 and 281. A little beyond
t h i s to the n o r t h t h e r e i s an abandoned m i l i t a r y
airfield. All t h r e e w i t n e s s e s a t this post s t a t e
that when the a i r c r a f t was o v e r h i l l s 224 and
281, i t broke up and fell in pieces. P a r t of
the d e b r i s f e l l on t h e n o r t h w e s t e r n s l o p e s of
the h i l l s and burned f o r a s h o r t t i m e . The
other p a r t f e l l on the s o u t h e a s t e r n s l o p e s and
continued burning for m o r e than an hour. When
the a i r c r a f t broke up i n m i d - a i r , i t was a t an
altitude of approximately 2 000 feet.
Other w i t n e s s e s stationed a t points "2"
and "3" ( s e e F i g u r e 21) f u r t h e r e a s t along t h e
s a m e b o r d e r h e a r d machine-gun f i r e before
the a i r c r a f t a p p e a r e d and then saw i t coming
low o v e r the mountain with f i r e and s m o k e a t
the r o o t of the right wing. They generally
confirmed the previous w i t n e s s e s r e g a r d i n g
t h e path t h e a i r c r a f t took. However, they saw,
in addition, two jet f i g h t e r s above the a i r c r a f t .
One of the jets d i s a p p e a r e d immediately a f t e r
the a i r c r a f t t u r n e d north but t h e other accom-
panied i t right up t o the t i m e when i t broke up.
After this i t c i r c l e d and flew to the north.
t i m e the a i r c r a f t broke up.
T h r e e other w i t n e s s e s , civilians, m a d e
t h e i r observations f r o m the vicinity of P r o m a -
chonos m a r k e d 4 on F i g u r e 21. One of t h e m
b r o k e up. The attention of t h e o t h e r s was
drawn t o the a i r c r a f t by what they d e s c r i b e d
a s tlnoise't. Of t h i s group of w i t n e s s e s two
saw the fighter.
Vicinity Yugoslav-Bulgarian B o r d e r
]point 0528) t o Break-up
In the light of the evidence of the eye-
w i t n e s s e s , both Yugoslav and C r e e k , the r e -
construction of t h e flight path m a y now b e
continued f r o m the point 0528. As mentioned
before, the a i r c r a f t m a y be p r e s u m e d t o have
continued to the Yugoslav-Bulgarian b o r d e r
without a l t e r i n g c o u r s e . The distance f r o m
f i r s t appeared t o the G r e e k eyewitnesses i s
17 nautical miles. The mountain i s about
a s coming low over it. We a s s u m e , t h e r e f o r e ,
an altitude of s o m e 8 000 feet, A s the a i r c r a f t
had r e p o r t e d a t 18 000 feet over the point 0528,
i t m u s t have l o s t approximately 10 000 f e e t of
altitude over a distance of 17 nautical m i l e s .
T l d s m e a n s that t h e a i r c r a f t m u s t have reduced
speed to the minimum in o r d e r to m a k e a r a p i d
descent. It m u s t have a v e r a g e d about 150 knots
over this distance which it would then have cov-
e r e d in 7 m i n u t e s , brlnging it over the mountain
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
a t 0536. L o s s of p r e s s u r i z a t i o n a s a r e s u l t of
d a m a g e t o t h e f u s e l a g e c a u s e d by o n e of t h e
e a r l i e r b u r s t s of f i r e m a y a c c o u n t f o r t h e v e r y
r a p i d d e s c e n t . (It w i l l b e r e m e m b e r e d t h a t t h e
Yugoslav witnesses h e a r d machine-gun f i r e
before the a i r c r a f t c a m e into view.) As the
Y u g o s l a v w i t n e s s e s h e a r d f i r e when t h e a i r c r a f t
d i s a p p e a r e d f r o m t h e i r view a n d t h e G r e e k wit-
n e s s e s heard f i r e just before the a i r c r a f t ap-
p e a r e d smoking into t h e i r view, i t s e e m s that
t h e a i r c r a f t w a s hit f o r a s e c o n d t i m e a n d a
f i r e started a s the aircraft came over the
m o u n t a i n . T h e SOS m e s s a g e w a s r e c e i v e d
a t 0537 w h i c h would b e i m m e d i a t e l y a f t e r t h e
fire started.
Why n o SOS m e s s a g e w a s r e c e i v e d e a r l i e r
i s a m a t t e r f o r c o n j e c t u r e . T h e c a u s e of t h e
s u d d e n l o s s of p r e s s u r i z a t i o n m a y not h a v e b e e n
immediately a p p a r e n t to the captain: His f i r s t
a c t i o n would h a v e b e e n t o l o s e h e i g h t a s r a p i d -
l y a s p o s s i b l e . At t h e s a r n e t l m e h e would h a v e
t r i e d t o find o u t t h e c a u s e of t h e l o s s of p r e s -
s u r i z a t i o n . I t m a y be t h a t i t w a s o n l y a t t h e
second attack that h e realized that the a i r c r a f t
was under fire.
T h e a i r c r a f t c o n t i n u e d on t o w a r d s P e t r i c i
a c c o m p a n i e d by t h e two f i g h t e r s . It w a s l c s i n g
height steadily. After c r o s s i n g the S t r u m i c a
River, i t turned left between P e t r i c i and the
G r e e k border. It then headed in a northerly
direction towards the Strumon valley until i t
r e a c h e d t h e h i l l s 224 a n d 281. Right u p t o t h i s
point the a i r c r a f t a p p e a r s to have been under
c o n t r o l a n d t h e p i l o t w a s m a k i n g f o r a landing
i n t h e S t r u m o n plain a n d p o s s i t ) l y on t h e a b a n -
doned m i l i t a r y a i r f i e l d n o r t h of t h e h i l l s . O n e
of t h e f i g h t e r s a c c o m p a n i e d t h e a i r c r a f t t o t h e
end.
F r o m t h e r e p o r t on t h e w r e c k a g e a n d
t e c h n i c a l i n v e s t i g a t i o n i t c a n be s e e n t h a t c e r -
t a i n d a m a g e w a s i n f l i c t e d in t h e a i r i m m e d i -
ately before the break-up. E x p l o s i o n s of l a r g e
c a l i b r e p r o j e c t i l e s i n t h e r e a r p a r t of t h e f u s e -
l a g e d a m a g i n g t h e c o n t r o l m e c h a n i s m of t h e
e l e v a t o r s a n d r u d d e r s would not h a v e p e r m i t t e d
t h e a i r c r a f t t o m a i n t a i n c o n t r o l l e d flight. F u r -
t h e r ~ n o r e ,p r o j e c t i l e s h a d p e n e t r a t e d t h e t a n k s
of t h e r i g h t wing a n d i t w a s c l e a r f r o m t h e s c a t -
t e r of t h e p i e c e s t h a t t h e wing h a d e x p l o d e d in
mid-air. T h e l e f t wing t a n k s h a d a l s o b e e n h i t
b y b u l l e t s which m u s t h a v e s t a r t e d a f i r e follow-
e d by a n e x p l o s i o n . T h e t e c h n i c a l i n v e s t i g a t i o n
p o i n t s t o t h e a i r c r a f t having e x p l o d e d a n d b r o k e n
u p o v e r t h e h i l l s a s a r e s u l t of a f i n a l a t t a c k .
The eyewitnesses' evidence supports this conclu-
s i o n . N e a r l y a l l of t h e m s a w t h e a i r c r a f t b r e a k
151
up in mid-air and s o m e s a w a fighter a c c o m -
panylng i t . T h e w i t n e s s e s t o t h e w e s t a n d
s o u t h of t h e h i l l s did n o t h e a r e i t h e r t h e e x p l o -
sion o r gun-fire. T h o s e a little f u r t h e r t o t h e
e a s t along the f r o n t i e r h e a r d the explosion and
s o m e of t h e m a l s o h e a r d g u n - f i r e .
T h e f a i l u r e of s o m e of t h e w i t n e s s e s t o
h e a r t h e s o u n d s of t h e e x p l o s i o n a n d g u n - f i r e
m a y b e due t o t h e s t r o n g w e s t e r l y wind which
w a s blowing a t t h e t i m e .
F r o m t h e c o n d i t i o n of t h e w r e c k a g e a n d
t h e e y e w i t n e s s e s t d e s c r i p t i o n of t h e b r e a k - u p
of t h e a i r c r a f t i n m i d - a i r t o g e t h e r with t h e
s t a t e r n e n t of t h e B u l g a r i a n G o v e r n m e n t , i t
may be conclusively p r e s u m e d that t h e r c w e r e
no s u r v i v o r s .
1. T h e f i r s t f i r i n g took p l a c e i n t h e a r e a
of t h e Y u g o s l a v - B u l g a r i a n b o r d e r a t
a n a l t i t u d e of a p p r o x i m a t e l y 18 000
feet. The Commission i s satisfied
t h a t thc a i r c r a f t d i d not r e c e i v e a n y
warning prior to this firing.
2. S e v e r a l m i n u t e s l a t e r t h e s e c o n d f i r i n g
took p l a c e o v e r B u l g a r i a n t e r r i t o r y a t
a n a l t i t u d e of a p p r o x i m a t e l y 8 000 f e e t .
The a i r c r a f t w a s then evidently i n
p r o c e s s of d e s c e n t s e e k i n g a p l a c e t o
l a n d a n d w a s showing s i g n s of f i r e .
Nevertheless i t continued i n controlled
fllght. At t h e t i m e of t h i s a t t a c k i t h a d
c o v e r e d s o m e 17 n a u t i c a l m i l e s within
Bulgarian a i r space.
3 . After approximately five minutes the
t h i r d a t t a c k took place a t a n altitude
of a b o u t 2 000 f e e t . T h e a i r c r a f t w a s
s t i l l under control, heading n o r t h w a r d
deeper into Bulgaria and making f o r a
f o r c e d landing. A s a r e s u l t of t h i s
l a s t attack, the a i r c r a f t broke up i n
mid-air.
4. T h e a i r c r a f t e n t e r e d B u l g a r i a n a i r -
s p a c e being approximately 3 5 nautical
m i l e s off t r a c k on a c o u r s e w h i c h
would h a v e b r o u g h t i t t o t h e B u l g a r i a n -
Greek border after traversing approxi-
n ~ a t e l y26 n a u t i c a l m i l e s ( 6 t o 7 m i n u t e s
f l y i n g ) of t h e s o u t h w e s t e r n c o r n e r of
Bulgaria. The Bulgarian statement
a s t o t h e c o u r s e a n d t r a c k of t h e a i r -
c r a f t i s i n c o n s i s t e n t with t h e f a c t s a s
proved,
152 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
5. In t h e c i r c u m s t a n c e s of wind a n d
weather on this flight, t h e c r e w could
not h a v e b e e n a w a r e of t h e a i r c r a f t ' s
d r i f t f r o m track. In any event, t h e
c a u s e of t h e d i s a s t e r w a s not t h i s de-
v i a t i o n but t h e a c t i o n of t h e B u l g a r i a n
f i g h t e r s i n s h o o t i n g down t h e a i r c r a f t .
A . D e s c r i p t i o n of t h e W r e c k a g e
( T h e t o t a l t i m e s p e n t on B u l g a r i a n
t e r r i t o r y by the t h r e e investigators
w a s only s l i g h t l y m o r e t h a n s e v e n
h o u r s of w h i c h a p p r o x i m a t e l y 3-1/2
h o u r s w e r e s p e n t on t r a v e l l i n g a n d
formalities. Thus, they w e r e able
to c a r r y out only a limited s u r v e y
and could not m a k e a complete inves-
tigation. )
T h e l o c a t i o n of t h e w r e c k a g e w a s n e a r t h e
Greek-Bulgarian border on Bulgarian t e r r i t o r y
a b o u t 9 k m N . E . of P e t r i c h . T h e w r e c k a g e w a s
found o n h i l l 224/281 o n t h e w e s t e r n b a n k of t h e
River Strumon. The wreckage was scattered
o n t h e S.E. a n d N. W. d e s c e n t s of t h e h i l l o v e r
a n a r e a of a p p r o x i m a t e l y 35 000 s q . m e t r e s ,
T h e t o p o g r a p h i c h e i g h t of t h e h i l l i s 232 m e t r e s .
T h e S o u t h - E a s t S i d e of t h e Hill
T h e m a j o r p a r t of t h e w r e c k a g e w a s on
t h e S. E. d e s c e n t of t h e h i l l . T h e a i r c r a f t
d e b r i s w a s found s c a t t e r e d , s o m e p a r t s b r o k e n
i n t o t h o u s a n d s of f r a g m e n t s . I t w a s i m p o s s i b l e
t o e x a m i n e a l l t h e p a r t s w h i c h w e r e lying a r o u n d .
T h e r e f o r e , only t h o s e p a r t s w e r e e x a m i n e d
which i n t h e opinion of t h e c o m m i t t e e a p p e a r e d
significant.
T h e following p a r t s a n d c o m p o n e n t s found
i n t h i s a r e a w e r e noted:
1. F o u r e n g i n e s . O n e e n g i n e h a d b e e n
disassembled and many p a r t s had been
r e m o v e d i n c l u d i n g 17 o u t of t h e 18 c y l -
i n d e r s , A s e c o n d e n g i n e w a s found i n
t h e w a t e r n e a r t h e r i v e r bank. A t h i r d
engine was i n the r i v e r p a r t l y sub-
m e r g e d . T h e f o u r t h e n g i n e w a s on t h e
s l o p e of t h e hill.
2. Two p a r t s of t h e c e n t r e s e c t i o n of t h e
f u s e l a g e w e r e found p a r t l y i n t h e w a t e r .
T h e y w e r e p u n c t u r e d by n u m e r o u s in-
w a r d pointing r o u n d a n d jagged h o l e s of
v a r i o u s s i z e s . I n t e r i o r lining w a s n l i s s -
ing f r o m t h e c a b i n w a l l s a n d w a s s c a t -
t e r e d on t h e g r o u n d . T h e lining s h o w e d
no s i g n s of f i r e .
#
One p a r t of t h e f u s e l a g e w a s t h e s e c -
tion w h e r e the wings a r e attached.
T h e r e w e r e s e v e r a l holes i n t h e fuse-
lage that had penetrated into the cabin
i n t h e v i c i n i t y of t h e r i g h t h e a t e r c o m -
partment. T h e r e were several l a r g e
and s m a l l holes in the right heater
compartment situated in the right
wing r o o t . P a r t of t h e h e a t e r a s s e m -
bly itself - the Janitor Combustion
H e a t e r - m a d e of s t a i n l e s s s t e e l w a s
m i s s i n g . I t h a d n o t b r o k e n off by
i m p a c t but h a d e v i d e n t l y b e e n d i s -
mantled.
In the h e a t e r c o m p a r t m e n t t h e r e w a s
a c l e a r i n d i c a t i o n of a f i r e i n f l i g h t
w i t h a "blow-tor chl' effect: a l u m i n i u m
a l l o y p a r t s h a d m e l t e d a w a y with d i -
minishing effect along a s t r a i g h t path
a g a i n s t t h e d i r e c t i o n of flight.
3. T h e l e f t wing, b r o k e n off f r o m t h e
f u s e l a g e a t t h e wing a t t a c h m e n t f i t -
tings, w a s lying on the ground i n one
p i e c e . T h e u n d e r s i d e a n d r i b s of t h e
wing h a d b e e n p a r t l y g u t t e d by f i r e .
N e a r l y a l l t h e r i b s h a d s h e a r e d off.
P a r t of t h e wing w a s l e s s s e r i o u s l y
d a m a g e d but e v e n h e r e s o m e r i v e t s
of t h e r i b s a n d l o w e r wing s k i n w e r e
s h e a r e d off.
T h e r e w e r e a n u m b e r of j a g g e d a n d
r o u n d h o l e s o n what r e m a i n e d of t h e
wing s k i n .
In t h e a r e a of t h e u p p e r s u r f a c e a t
No. 2 tank, j u s t behind t h e r e a r s p a r ,
t h e r e w e r e i n w a r d pointing h o l e s . In
the r e a r s p a r web t h e r e w a s a round
i n w a r d p e n e t r a t i o n , n i r a s u r i n g 14 m m
in diameter.
4. O n e c o m p l e t e u n d e r c a r r i a g e , w i t h
wheels in r e t r a c t e d position, w a s
found i n t h e r i v e r .
T h e w h e e l a s s e m b l y of t h e s e c o n d
u n d e r c a r r i a g e was on the e a s t e r n
bank of t h e r i v e r .
5. T h e only r a d i o e q u i p m e n t found w e r e
two r a d i o s e t s b a d l y s m a s h e d . There
w e r e no r a d i o dials.
6 . Of t h e i n s t r u x n e n t s t h e r e w a s only o n e
r a d i o c o m p a s s showing a h e a d i n g of
114O a n d a n e e d l e s e t t i n g of 88O.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
7, S o m e twisted s e a t s t r u c t u r e s w e r e
found but t h e s e accounted only f o r a
s m a l l p a r t of a l l t h e s e a t s . The r e s t
w e r e m i s s i n g , A p a r t l y burned safety
belt was noted with the lock in c l o s e d
position.
8. Two p r o p e l l e r hubs w e r e found, on
one of which t h e r e w a s an e n t i r e l y
undamaged blade.
9. An e l e c t r i c a l high tension line of about
6 000 volts, running on t h e w e s t e r n
bank of t h e r i v e r , w a s found s e v e r e d ,
lying on t h e d e b r i s . Two broken wood-
en poles w e r e on t h e s i t e , one of t h e m
s t r o n g l y burned.
10. Of t h e m a n y panels lining the f r o n t and
r e a r c a r g o c o m p a r t m e n t in the body of
t h e f u s e l a g e , only one was found, a
v e r t i c a l panel. It w a s p i e r c e d by 12-
15 round h o l e s u p t o 15 m m . i n d i a m -
eter.
11. Many s m a l l e r p i e c e s lying around, not
specified above, w e r e p i e r c e d by round
and jagged holes.
12. T h e r e w e r e indentations on the ground
w h e r e heavy p a r t s had been imbedded
but t h e p a r t s w e r e found quite a d i s -
t a n c e away, u n r e l a t e d i n t h e i r location
t o t h e o r i g i n a l l m p r i n t s i n t h e ground.
T h e North-West Side of t h e Hill
On t h i s s i d e the w r e c k a g e was m o r e widely
s c a t t e r e d than on t h e s o u t h e a s t s i d e and c o n s i s t -
e d m a i n l y of m a j o r p a r t s .
13. T h e r i g h t wing was b r o k e n off a t t h e
a t t a c h m e n t fittings f r o m t h e f u s e l a g e
a n d broken in t h r e e l a r g e p a r t s which
w e r e lying a t a d i s t a n c e of about 80
m e t r e s one f r o m a n o t h e r , At the i n n e r
p a r t of the i n n e r wing, t h e s k i n was
s e p a r a t e d f r o m the few r i b s r e m a i n i n g .
The tank a r e a of t h i s p a r t of t h e wing,
between t h e f r o n t and t h e r e a r s p a r ,
w a s a l m o s t e n t i r e l y b u r n e d out and t h e
m e t a l of s h e e t s and e x t r u s i o n s was
m e l t e d down. The ground below t h e
wing showed a f i r e running downhill,
obviously fed by the r e m a i n i n g f u e l of
t h e wing a t t h e t i m e of i m p a c t . In t h e
o u t e r p a r t of the i n n e r wing, in the
vicinity of t h e engine n a c e l l e s , t h e r e
w e r e indications of a l e s s i n t e n s e f i r e
and t h e r e was l e s s d e s t r u c t i o n than in
153
t h e i n n e r p a r t . H e r e it w a s s t i l l p o s -
s i b l e to find and identify s o m e h o l e s
c a u s e d by t h e p e n e t r a t i o n of p r o j e c -
t i l e s . (Some of t h e s e w e r e of l a r g e
calibre. )
T h e o u t e r wing c a r r y i n g t h e a i l e r o n
was p a r t l y undamaged. H e r e , too,
t h e r e w a s a f i r e of l e s s e r intensity.
The f a b r i c w a s s t r i p p e d c l e a n f r o m
t h e a i l e r o n which showed no s i g n s of
fire.
14. T h e f u s e l a g e between t h e wing t r a i l i n g
edge a n d the r e a r p r e s s u r e bulkhead
was s m a s h e d into s e v e r a l p i e c e s , a l l
of t h e m s t r o n g l y d i s t o r t e d and a l m o s t
beyond recognition. H e r e , again, a
n u m b e r of h o l e s of d i f f e r e n t s i z e s w e r e
noted. All f i b r e g l a s s and f a b r i c lining
of t h e a c c e s s i b l e cabin s e c t i o n s w a s
s t r i p p e d f r o m t h e i n s i d e of the f u s e -
lage. T h e s t e w a r d ' s c a l l button box
c o v e r w a s found u n s c r e w e d and open.
15. T h r e e blankets w e r e found n e a r t h e
f u s e l a g e , e a c h p r e s s e d into a tight
plug-like bundle. T h e s m a l l e r end of
e a c h bundle w a s c h a r r e d .
16. Two c o m p l e t e i n n e r f l a p s e c t i o n s ,
lying s e p a r a t e l y , showed a n u m b e r
of round holes.
17. T h e r e a r p a r t of t h e f u s e l a g e w a s
s e v e r e d f r o m t h e m a i n body a t t h e
r e a r p r e s s u r e bulkhead. T h e r e w a s
an i n w a r d pointing hole on the l o w e r
p a r t of t h e r i g h t s i d e a f t of t h e bulk-
head. The hole was b r o a d , o v a l i n
shape, with a m i n i m u m d l a n l e t ~ rof
85 m m . T h e d i r e c t i o n of p e n e t r a t i o n
w a s a p p r o x i m a t e l y 15O f r o m t h e r e a r
t o t h e h o r i z o n t a l c e n t r e l i n e of the
a i r c r a f t . No c o r r e s p o n d i n g outlet t o
t h i s hole could be found.
T h e r e a r p r e s s u r e bulkhead in t h i s
p a r t of the f u s e l a g e however was
p i e r c e d by a g r e a t n u m b e r of r o u n d
and jagged h o l e s m o s t of t h e m point-
ing outwards. T h e r e w a s a l s o a l a r g e
opening t o r n in t h e p r e s s u r e bulkhead.
T h e bottom s e g m e n t of t h e s e c o n d
r i n g f r o m t h e t a i l cone a t t a c h m e n t
point w a s p i e r c e d by two holes f r o m
r e a r t o n o s e m e a s u r i n g 63 m m . and
75 m m . r e s p e c t i v e l y .
154 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
T h e walking b e a m of t h e e l e v a t o r w a s
found d e t a c h e d f r o m i t s b r a c k e t .
T h e f u s e l a g e s t r u c t u r e i n t h e a r e a of
a t t a c h m e n t of t h e e m p e n n a g e s h o w e d
a n u m b e r of h o l e s .
On t h e b o t t o m of t h e f u s e l a g e u n d e r -
n e a t h t h e walking b e a m a t t a c h m e n t
. b r a c k e t s t h e r e w a s a jagged opening
i n t h e s k i n with a d i a m e t e r of 170 m m .
T h e r e w e r e i n d i c a t i o n s o f a not v e r y
intense f i r e around the emergency
elevator booster s y s t e m apparently
s u s t a i n e d by t h e h y d r a u l i c f l u i d of t h e
m a i n hydraulic s y s t e m and the e m e r -
5ency b o o s t e r s y s t e m including t h e
accumulators situated in this a r e a .
18. T h e e m p e n n a g e of the a i r c r a f t w a s
b r o k e n i n t o t h r e e p i e c e s which w e r c
found 150 m e t r e s a p a r t .
M o s t of t h e s t a b i l i z e r a n d t h t c e n t r e
f i n w e r e lying n e a r t h e b o t t o m of t h e
h i l l . A s m a l l e r p i e c e of t h e s t a b i l i z e r
with t h e l e f t f i n a n d r u d d e r w e r e c l o s e
t o t h e t o p of t h e h i l l . T h e r i g h t p a r t
of t h e s t a b i l i z e r , t h e e l e v a t o r a n d t h e
r i g h t f i n a n d r u d d e r w e r e n e a r t h e bot-
t o m of t h e h i l l , not s e v e r e l y s m a s h e d .
P i e c e s of t h i s s e c t i o n , a d j o i n i n g t h e
f u s e l a g e h a d b e e n c u t a w a y with cutting
t o o l s a n d c o u l d not b e found.
I n t h e s t r u c t u r e of t h e e m p e n n a g e ,
where i t attaches to the fuselage, t h e r e
w e r e a n u m b e r of h o l e s .
19. D e i c e r b o o t s w e r e c l e a r l y c u t by s h a r p w a s c l e a r f r o m t h e f a c t t h a t t h e f i r e t h a t h a d
i n s t r u m e n t s a n d s o m e of t h e s e c t i o n s
of r e g u l a r r e c t a n g u l a r s h a p e w e r e m i s s - j a c e n t v e g e t a t i o n a n d m e l t e d m a t e r i a l f r o m a l l
ing.
20. T h e s i x high p r e s s u r e o x y g e n b o t t l e s
a n d o n e w a l k - a r o u n d oxygen b o t t l e w e r e
found i n t a c t .
21. Many m a j o r c o m p o n e n t s a n d s e c t i o n s
c o u l d not be found, C o n s p i c u o u s l y
m i s s i n g w a s t h e s e c t i o n of t h e f u s e l a g e
f r o m s e c t i o n 290 f o r w a r d which i n c l u d e s 2 ) . T h e f i r e h e r e m u s t h a v e b u r n e d s o m e t i m e
t h e cockpit.
22. In addition to the holes mentioned in
t h e above description t h e r e w e r e many
o t h e r h o l e s of s i z e s r a n g i n g f r o m 8 t o
85 m m ,
2 3 . D e s p i t e t h e l a r g e n u m b e r of h o l e s n o
p r o j e c t i l e s o r f r a g m e n t s of p r o j e c t i l e s
w e r e found.
B. D i s c u s s i o n
The i t e m numbers used in this Discus-
sion r e f e r t o the n u m b e r s in Description A
above.
1. Nothing w a s found i n t h e w r e c k a g e
available for inspection t o indicate that t h e r e
h a d b e e n any d e f e c t s o r f a i l u r e s d u e t o m a l -
functioning.
2. T h e r e w a s c o n s i d e r a b l e e v i d e n c e t h a t
t h e w r e c k a g e h a d b e e n i n t e r f e r e d with b e f o r e
the conlmittee's a r r i v a l . I t had been noted that
m a n y p a r t s had been removed, including n e a r l y
a l l r a d i o e q u i p m e n t a n d i n s t r u m e n t s . ( I t e m s 5,
6 . ) T h e s e m a y have provided useful informa-
tion. In a d d i t i o n , m a n y p a r t s h a d b e e n d i s -
nlantled, cut away and/or removed. Among
t h e s e w e r e engine cylinders (Item l ) , i n t e r i o r
lining ( I t e m s 2, 14), t h e h e a t e r ( I t e m 2 ) , m o s t
of t h e s e a t s ( I t e m 7), p o r t i o n of t h e e m p e n n a g e
( I t e m 18), d e i c e r b o o t s ( I t e m 19), a n d t h e w h o l e
of t h e c o c k p i t ( I t e m 21).
F u r t h e r m o r e , m a r k s on t h e g r o u n d i n d i -
c a t e d that heavy p a r t s had been shifted f r o m
t h e p o s i t i o n s i n which t h e y h a d f a l l e n . A t
l e a s t p a r t of t h e i n t e r f e r e n c e a b o v e c o u l d not
h a v e b e e n o c c a s i o n e d by r e s c u e o p e r a t i o n s .
In s p i t e of t h e e x t e n s i v e i n t e r f e r e n c e
with t h e w r e c k a g e i t c o u l d be d e t e r m i n e d t h a t
s o m e of t h e p a r t s w e r e lying w h e r e t h e y h a d
f a l l e n . F o r e x a m p l e , t h e t h r e e p i e c e s of t h e
r i g h t wing w e r e in t h e i r o r i g i n a l p o s i t i o n . T h i s
b u r n e d i n o n e of t h e p i e c e s e x t e n d e d t o t h e ad-
t h r e e p i e c e s w a s lying o n t h e g r o u n d b e n e a t h
t h e p l a c e s f r o m which t h e m e t a l h a d m e l t e d
away.
3 . T h e r e w a s a c l e a r i n d i c a t i o n of a
f i r e having s t a r t e d s o m e t i m e before the final
b r e a k - u p a n d having c o n t i n u e d i n f l i g h t f o r
s e v e r a l minutes. The evidence for this was
t h e condition of t h e h e a t e r c o m p a r t m e n t ( I t e m
in flight i n o r d e r t o have melted the aluminium
a l o n g a s t r a i g h t p a r t r u n n i n g f r o m f o r e t o aft.
T h e m e l t i n g of t h e a l u m i n i u m d e c r e a s e d a l o n g
t h e pdth. T h i s f i r e w a s i n t e n s i f i e d by t h e s l i p -
s t r e a m t o which t h l s a r e a w a s e x p o s e d by
r e a s o n of t h e h o l e s in t h e c o m p a r t m e n t . T h e
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
s i z e of t h e p r o j e c t i l e s t h a t h a d e n t e r e d could
not b e d e t e r m i n e d owing t o t h e d e f o r m a t i o n of
the m a t e r i a l through heat and impact.
4. T h e t h r e e b l a n k e t s , bundled i n t o p .l u g s
a n d c h a r r e d a t o n e end ( I t e m 15) s u g g e s t t h a t
-
smoke and f i r e w e r e entering the cabin and
e f f o r t s w e r e being m a d e t o s t o p t h e h o l e s . T h i s
s u p p o r t s t h e view e x p r e s s e d a b o v e , t h a t a f l t e
had s t a r t e d s o m e t i m e before the break-up. It
f u r t h e r indicates that p r e s s u r i z a t i o n m u s t have
been lost a t this e a r l i e r stage.
5. T h e condition of t h e l e f t wing ( I t e m 3 ) ,
i n d i c a t e d a n explosion. R i b s a n d r i v e t s w e r e
s h e d r e d off in a m a n n e r t h a t c o u l d not h a v e b e e n
c a u s e d by f i r e o r i m p a c t . T h e r o u n d h o l e s i n
t h e s k i n of t h e wing a n d i n t h e a r e a of t h e u p p e r
s u r f a c e of t h e t a n k behind t h e r e a r s p a r a n d t h e
h o l e in t h e r e a r s p a r web a p p e a r t o h a v e b e e n
c a u s e d by b u l l e t s . B u l l e t s h i t t i n g in t h i s a r e a
would c a u s e a f i r e followed by a n e x p l o s i o n . I t
i s probable t h e r e f o r e that t h e a t t a c k on the a i r -
c r a f t , i n t h e c o u r s e of which t h e s e b u l l e t h o l e s
w e r e inflicted, o c c u r r e d a t , o r immediately
before the final break-up.
6. T h e r e w a s e v i d e n c e t h a t t h e r i g h t wing
had exploded and that the explosion had taken
place in mid-air. R i v e t s holding t h e r i b s t o
t h e s k i n h a d b e e n s h e a r e d off. T h e t h r e e p i e c e s
of t h e wing w e r e lying a t a d i s t a n c e of a b o u t 80
m e t r e s one f r o m the other. As explained be-
f o r e , the pieces w e r e where they had originally
f a l l e n a n d could not h a v e b e e n s o widely s c a t -
t e r e d e x c e p t by m i d - a i r e x p l o s i o n .
7. T h e n u m e r o u s h o l e s ill t h e c a r g o c o m -
p a r t m e n t p a n e l ( I t e m 10) w e r e c a u s e d by b u l l e t s
of d i f f e r e n t c a l i b r e s . Only o n e c o u l d b e m e a s -
u r e d with r e l i a b i l i t y f r o m t h e p h o t o g r a p h s . I t s
d i a m e t e r w a s 14 m m . T h e s e h o l e s w e r e r o u n d
and the panel they penetrated had been i n a
v e r t i c a l position. They m u s t t h e r e f o r e have
b e e n c a u s e d by b u l l e t s f i r e d f r o m a d i r e c t i o n
m o r e o r l e s s horizontal to the a i r c r a f t .
8 . T h e r e a r p a r t of t h e f u s e l a g e ( I t e m 17)
w a s h e a v i l y p i e r c e d by h o l e s , i n c l u d i n g s o m e of
l a r g e d i a m e t e r . O n e of t h e s e l a r g e r h o l e s w a s
c a u s e d by a p r o j e c t i l e e n t e r i n g t h e u n p r e s s u r i z e d
p a r t of t h e f u s e l a g e a t a n a c u t e a n g l e f r o m t h e
r e a r . I t m u s t h a v e t h e n exploded, c u t t i n g t h e
rllany o u t w a r d pointing h o l e s i n t h e s k i n a n d t h e
f o r w a r d pointing r e n t s i n t h e r e a r p r e s s u r e b u l k -
h e a d . One of t h e s e w a s a l a r g e r e n t 40 X 9 0 c m .
F r o m t h e a n g l e of p e n e t r a t i o n i t c a n be c o n c l u d e d
that the projectile was f i r e d f r o m an a i r c r a f t .
Its s i z e and explosive effect suggest a rocket.
155
T h e two h i t s i n t h e s e c o n d r i n g f r o m t h e
t a i l c o n e i n t h i s a r e a w e r e a l s o c a u s e d by
l a r g e calibre projectiles. They m u s t have
been f i r e d f r o m the r e a r .
T h e d a m a g e t h e y c a u s e d c o u l d not b e
clearly determined. They m a y have brought
a b o u t t h e d e t a c h m e n t of t h e walking b e a m .
They m a y have a l s o caused t h e f i r e noted
around the emergency booster system.
T h e e x p l o s i v e e f f e c t of t h e s e t h r e e l a r g e
projectiles behind the r e a r p r e s s u r e bulkhead,
w h e r e m o s t of t h e e l e v a t o r a n d r u d d e r c o n t r o l
m e c h a n i s m i s s i t u a t e d , would p r e v e n t t h e a i r -
c r a f t f r o r n being flown u n d e r c o n t r o l .
9. T h e r e q u e s t t o t h e B u l g a r i a n G o v e r n -
m e n t t o allow a s e c o n d a c c e s s t o t h e w r e c k a g e
of a c o m m i t t e e o r two, i n c l u d i n g t h e a r m a m e n t
e x p e r t , was not granted. The conclusions
a r r i v e d a t a s t o t h e t y p e a n d s i z e of p r o j e c t i l e s
which h i t t h e a i r c r a f t w e r e r e a c h e d by t h e Corn-
mission after the a r m a m e n t expert had exam-
i n e d photos dnd s k e t c h e s a n d h a d r e c e i v e d
r e p o r t s o n t h i s a s p e c t of t h e i n v e s t i g a t i o n
f r o m t h e t h r e e m e m b e r s of t h e C o m m i s s i o n
who h a d h a d a c c e s s t o t h e w r e c k a g e .
Probable Cause
The a i r c r a f t sustained a hit o r hits which
~ a u s e dl o s s of p r e s s u r i z a t i o n a n d a f i r e i n t h e
heater compartment. The aircraft broke up
in m i d - a i r d u e t o e x p l o s i o n c a u s e d by b u l l e t s
h i t t i n g t h e r i g h t wing a n d p r o b a b l y t h e l e f t
wing t o g e t h e r with a p r o j e c t i l e o r p r o j e c t i l e s
of l a r g e c a l i b r e b u r s t i n g i n t h e r e a r e n d of t h e
fuselage.
Recommendations
Throughout the European a n d Middle
E a s t r e g i o n s t h e r e a r e a n u m b e r of a i r w a y s
w h i c h a r e not a d e q u a t e l y e q u l p p e d with r a d i o
navigational a i d s ensuring that pilots a r e given
a r e l i a b l e t r a c k i n g when t h e y n e e d i t m o s t , t h a t
i s t o s a y , in b a d w e a t h e r . N o n - d ~ r e c t i o n a l
beacons a r e inadequate aids unless supplement-
e d by o t h e r n a v i g a t i o n a l a i d s s u c h a s r a d a r
s u r v e i l l a n c e of t h e kind p r o v i d e d , f o r e x a m p l e ,
i n E n g l a n d . With NDB1s a l o n e p i l o t s w i l l b e
unable to avoid deviations f r o m the a i r w a y s .
T h e I n t e r n a t i o n a l C l v i l Aviation O r g a n i z a t i o n
h a s r e c o m m e n d e d a m o r e e x t e n s i v e u s e of
VOR1s which not only give a n a d e q u a t e t r a c k
but a r e a l s o u n a f f e c t e d by b a d w e a t h e r ( s t a t i c ) .
156 ICAO C i r c u l a r 50-AN/45
The route Belgrade-Salonika (Airway
A m b e r 10) o v e r a d i s t a n c e of 284 n a u t i c a l
m i l e s i s e q u i p p e d with o n l y o n e VOR ( a t B e l -
g r a d e ) a n d 3 NDB's ( a t B e l g r a d e , S k o p l j e a n d
S a l o n i k a ) but h a s f i v e c o m p u l s o r y r e p o r t i n g
p o i n t s elgr grade, K r a l j e v o , S k o p l j e , G e v g e l i a
a n d Salonika). I n p r a c t i c e , t h e A i r w a y A m b e r
10, when flown f r o m B e l g r a d e i n b a d w e a t h e r ,
c a n b e followed with a c c u r a c y only f o r t h e f i r s t
70 m i l e s with t h e a i d of t h e B e l g r a d e VOR.
I t i s , t h e r e f o r e , r e c o m m e n d e d that:
a ) N a v i g a t i o n a l a i d s which a r e not a f f e c t e d
by s t a t i c s h o u l d b e i n t r o d u c e d a l o n g
A i r w a y A m b e r 10 t o s u p p l e m e n t t h e
p r e s e n t NDB's a n d s h o u l d c o v e r t h e
whole A i r w a y .
b) All compulsory reporting points should
be equipped with r a d i o n a v i g a t i o n a l a i d s .
A s f a r a s t h e C o m m i s s i o n i s a w a r e , no
communication watch on ground to a i r frequen-
c i e s , u s e d by a i r c r a f t o n t h i s r o u t e , i s k e p t by
the Bulgarian communication c e n t r e s nor a r e
they obliged t o keep such a watch.
I t i s , t h e r e f o r e , r e c o m m e n d e d that:
a ) A continuous w a t c h b e m a i n t a i n e d on
appropriate ground t o a i r frequencies
by t h o s e g o v e r n m e n t s which h a v e e s t a b -
l i s h e d p r o h i b i t e d a r e a s i n p r o x i m i t y of
international airways,
b) T h e r e i s a l s o n e e d f o r a s t a n d a r d a i r
t o a i r c o d e of v i s u a l s i g n a l s i n t h e
a b s e n c e of r a d i o c o m m u n i c a t i o n s and/
o r a common language.
F i n a l l y , t h e C o m m i s s i o n i s of t h e opinion
that t h e r e i s urgent need for co-ordinated inter-
n a t i o n a l a c t i o n t o p r e v e n t t h e s h o o t i n g down of
civil aircraft.
The Commission, therefore, recommends
t o t h e Go-vernment t o e x a m i n e w h a t s t e p s m a y
b e t a k e n t o t h i s e n d t h r o u g h t h e U N , ICAO a n d
otherwise.
" B u l g a r i a n Note of 4 A u g u s t 1955
IVlinistry of F o r e i g n A f f a i r s
NOTE V E R B A L E
T h e M i n i s t r y of F o r e i g n A f f a i r s of t h e B u l g a -
r i a n P e o p l e ' s Republic p r e s e n t s i t s compliments
t o t h e L e g a t i o n of I s r a e l i n S o f i a a n d , i n r e p l y
t o t h e l a t t e r ' s note N o . ~ / 0 4 8 5 / 0 2 , h a s t h e
h o n o u r t o c o m m u n i c a t e t h e following, o n
i n s t r u c t i o n s of i t s G o v e r n m e n t :
T h e following f a c t s h a v e b e e n e s t a b l i s h e d
beyond doubt by t h e m i n i s t e r i a l c o m m i s s i o n of
inquiry:
A t 0710 h o u r s ( l o c a l t i m e ) o n 27 J u l y
1955, a n a e r o p l a n e of t h e I s r a e l i a i r l i n e " E l Al"
p e n e t r a t e d B u l g a r i a n a i r s p a c e without n o t i c e i n
t h e a r e a cf t h e town of T r n . A f t e r p e n e t r a t i n g
i n t o B u l g a r i a n t e r r i t o r y t o a d e p t h of 40 kilo-
m e t r e s , the aeroplane then flew o v e r the towns
of B r e z n i k , R a d o m i r , S t a n k & - D i m i t r o v a n d
B l a g o e v g r a d a n d p r o c e e d e d t o w a r d s t h e South.
It flew o v e r Bulgarian t e r r i t o r y f o r a d i s t a n c e
of a p p r o x i m a t e l y 200 k i l o m e t r e s .
South of t h e town of S t a n k & - D i m i t r o v , t h e
a e r o p l a n e w a s i n t e r c e p t e d by two B u l g a r i a n
f i g h t e r s which had r e c e i v e d ordei-s t o compel
i t to land a t a Bulgarian airport.
The f i g h t e r s warned the aeroplane to land,
i n a c c o r d a n c e with e s t a b l i s h e d i n t e r n a t i o n a l
r u l e s . In s p i t e of t h i s , t h e a e r o p l a n e d i d n o t
c o m p l y , but c o n t i n u e d t o f l y s o u t h w a r d s , a t -
tempting t o escape a c r o s s the Bulgarian-Greek
frontier.
I n t h e c i r c u m s t a n c e s , t h e two f i g h t e r s of
the local Bulgarian a i r defence forces, s u r -
p r i s e d a t t h e a c t i o n s of t h e a e r o p l a n e , o p e n e d
f i r e , a s a r e s u l t of which t h e a e r o p l a n e c a u g h t
f i r e a n d c r a s h e d a l i t t l e l a t e r in t h e v i c i n i t y of
t h e t o w n of Pi5tritc h.
In a d o p t i n g t h e c o n c l u s i o n s r e a c h e d by
the special ministerial commission instructed
to inquire into this incident, the Bulgarian
G o v e r n m e n t a d m i t s t h a t t h e c a u s e s of t h e un-
f o r t u n a t e a c c i d e n t t o t h e " E l All1 a e r o p l a n e c a n
be s u m m a r i z e d a s follows:
1. T h e a e r o p l a n e d e v i a t e d f r o r n i t s r o u t e ,
v i o l a t e d t h e S t a t e f r o n t i e r of B u l g a r i a
and penetrated deep into the i n t e r i o r
of t h e B u l g a r i a n a i r s p a c e without
w a r n i n g . E q u i p p e d a s i t w a s with
perfect a i r navigation devices, the
a e r o p l a n e c a n n o t h a v e b e e n u n a w a r e of
the fact that it violated the State fron-
t i e r of B u l g a r i a . E v e n a f t e r i t h a d
been warned, i t failed to comply and
c o n t i n u e d t o fly s o u t h w a r d s i n t h e
d i r e c t i o n of t h e B u l g a r i a n G r e e k f r o n -
tier.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 157

2. The Bulgarian a i r defence f o r c e s The Bulgarian Government and P e o p l e

acted with s o m e h a s t i n e s s and did e x p r e s s once again t h e i r deep r e g r e t a t t h i s
not take a l l n e c e s s a r y m e a s u r e s t o g r e a t misfortune which c a u s e d the death of
compel the a i r c r a f t to s u r r e n d e r and e n t i r e l y innocent p e r s o n s . The Bulgarian
land. Government fervently hopes t h a t s u c h m i s -
f o r t u n e s will n e v e r r e c u r , I t will d i s c o v e r
3. The Bulgarian Government c o n s i d e r s and punish those r e s p o n s i b l e f o r t h e c a t a s t r o -
i t n e c e s s a r y t o draw attention a l s o to
phe in which the I s r a e l i a e r o p l a n e was involved
t h e f a c t that, f o r many y e a r s , c e r t a i n
and will t a k e a l l n e c e s s a r y s t e p s t o e n s u r e that
p a r t i e s , failing to r e s p e c t t h e s o v e r -
s i m i l a r c a t a s t r o p h e s do not r e c u r i n Bulgarian
eignty of the Bulgarian People's Re-
territory.
public, have systematically been
violating the Bulgarian f r o n t i e r s . In
The Bulgarian Government extends i t s
r e c e n t y e a r s many illegal c r o s s i n g s
deep sympathy t o t h e r e l a t i v e s of t h e v i c t i m s
of the Bulgarian f r o n t i e r s by a e r o -
and i s r e a d y t o undertake to pay compensation
planes "of unknown nationalityv have
due t o t h e i r f a m i l i e s , as well a s t o b e a r i t s
been recorded. During t h e s e illegal
s h a r e of the m a t e r i a l damages.
flights, s u b v e r t e r s equipped with
a r m s , r a d i o stations and other sup-
plies w e r e parachuted into Bulgarian
t e r r i t o r y . The Government of the
Bulgarian P e o p l e ' s Republic protested M i n i s t r y of F o r e i g n Affairs
s e v e r a l t i m e s to the S e c r e t a r i a t of the of the
United Nations Organization. Unfor- Bulgarian P e o p l e ' s Republic"
tunately, however, this produced no
r e s u l t s . All t h e s e f a c t o r s c r e a t e d a
tense a t m o s p h e r e which m a d e i t n e c e s -
s a r y to take s t e p s t o safeguard the Sofia. 4 August 1955
s e c u r i t y of the State. I t was t h i s tense
a t m o s p h e r e that made possible the un-
fortunate accident t o the I s r a e l i a e r o - The Legation of I s r a e l
plane. Sofia.

ICAO Ref: ~ ~ / 3 8 9
158 ICAO Circular 50-AN/ 45
*

F i g u r e 20
160 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5

No. 36

A l n e r i c a n A i r l i n e s , Inc. , Convair 240, c r a s h e d a t F o r t L e o n a r d Wood, M i s s o u r i ,

on 4 August 1955. Civil A e r o n a u t i c s B o a r d (USA) Accident Investigation R e p o r t
No. SA-309, F i l e No. 1-01 1 0 , r e l e a s e d 9 D e c e m b e r 1955.

"This a c c i d e n t r e s u l t e d i n the l a r g e s t l o s s of life

of a n y a i r c r a f t f i r e a c c i d e n t i n the U.S. d u r i n g
1955.

National F i r e P r o t e c t i o n A s s o c i a t i o n Bulletin No. 142

Circumstances could not r e a c h t h e s c e n e until the A r m y engi-

The flight was a scheduled operation be-
tween T u l s a , Oklahoma, and L a G u a r d i a F i e l d ,
New York, with s t o p s a t Joplin, Springfield and
S t . L o u i s , M i s s o u r i . It d e p a r t e d T u l s a a t 1006
C e n t r a l Standard T i m e c a r r y i n g a c r e w of t h r e e
and e i g h t p a s s e n g e r s . Stops w e r e m a d e a t
Joplin and Springfield and a t the l a t t e r point two
p a s s e n g e r s deplaned and twenty one b o a r d e d the
flight bringing the p a s s e n g e r t o t a l to twenty s e v -
e n . T h e a i r c r a f t d e p a r t e d Springfield V F R f o r
S t . Louis a t 1153 CST v i a Victor Airway 14 to
c r u i s e a t 7 000 f e e t . A t 1217 the c r e w initiated
a g e n e r a l c a l l asking "Does anyone r e a d 4 7 6 ? I f ,
which Springfield company r a d i o acknowledged
but r e c e i v e d no reply. Two o t h e r A m e r i c a n
A i r l i n e s flights, one c r u i s i n g in the vicinity of
Springfield, the other 30 m i l e s n o r t h - n o r t h e a s t
of S t . L o u i s , h e a r d a t r a n s m i s s i o n f r o m the
flight t h a t No. 2 engine was on f i r e . T h r e e m i n -
u t e s l a t e r the A m e r i c a n A i r l i n e s flight i n t h e
Springfield a r e a i n t e r c e p t e d the following m e s -
s a g e "Springfield, a r e you r e a d i n g 4 7 6 1 We
have bad engine f i r e . ' I T h i s was the l a s t m e s -
s a g e h e a r d f r o m t h e a i r c r a f t . At a p p r o x i m a t e l y
1222 h o u r s t h e o p e r a t i o n s officer on duty a t
F o r n e y F i e l d , F o r t L e o n a r d Wood, r e c e i v e d a
r a d i o m e s s a g e f r o m a n A r m y pilot flying n e a r b y
t h a t a two-engine a i r c r a f t with a f i r e i n the r i g h t
engine was o n final a p p r o a c h to Runway 14. The
tower o p e r a t o r a t F o r n e y Field s a w the a p -
proaching a i r c r a f t and gave i t c l e a r a n c e to land.
Before the o p e r a t i o n s officer could a l e r t t h e
c r a s h c r e w the a i r c r a f t c r a s h e d s h o r t of the run-
way in a d e n s e l y wooded a r e a about one-half
m i l e northwest of Runway 14, F o r n e y F i e l d , a t
1223 h o u r s , T h e r e w e r e n o s u r v i v o r s .
Investigation and Evidence
A r m y p e r s o n n e l with p o r t a b l e f i r e -
fighting equipment r e a c h e d the wreckage on foot.
Heavy fire-fighting equipment and a m b u l a n c e s
n e e r s had bulldozed a r o a d through the d e n s e l y
wooded a r e a i n which the c r a s h o c c u r r e d .
Investigation r e v e a l e d t h a t t h e r i g h t
wing, r i g h t engine, r i g h t landing g e a r , and a s -
s o c i a t e d p a r t s had s e p a r a t e d f r o m the a i r c r a f t
i n flight, and that b i t s and p i e c e s , including the
r i g h t inboard landing g e a r d o o r , had fallen f r o m
t h e a i r c r a f t b e f o r e the wing c a m e off. T h e r e -
m a i n d e r of rhe a i r c r a f t s t r u c k t h e ground a p p r o x -
i m a t e l y 300 feet beyond w h e r e t h e r i g h t wing
f e l l . Ground f i r e and i m p a c t d a m a g e was exten-
s i v e and much of the wreckage c o n s i s t e d of
b u r n e d rubble only. All m a j o r components,
h o w e v e r , w e r e accounted f o r a t t h e a c c i d e n t
s i t e . Evidence indicated t h a t the landing gedr
had not b e e n extended, and that the f l a p s w e r e
i n the full-up position.
Examination of the r i g h t engine showed
t h a t the No. 12 cylinder had b r o k e n c i r c u m f e r -
entially just above the hold-down flange. The
flange p o r t i o n r e m a i n e d with the engine; t h e
r e m a i n d e r of the c y l i n d e r , with the piston jam-
m e d i n the open e n d of the b a r r e l , was found
a p p r o x i m a t e l y 70 f e e t d i s t a n t . T h e piston pin
eye of the No. 12 link r o d w a s b r o k e n and the
piston pin lay about 30 f e e t f r o m the engine.
Damage t o the link r o d w a s r e l a t i v e l y m i n o r .
O t h e r p a r t s a s s o c i a t e d with the r i g h t engine
n a c e l l e w e r e s c a t t e r e d throughout this g e n e r a l
a r e a . Two b l a d z s of the r i g h t p r o p e l l e r , which
had been f e a t h e r e d , w e r e b r o k e n a t i m p a c t .
All p a r t s believed t o b e p e r t i n e n t to con-
tinued investigation of the a c c i d e n t w e r e r e -
moved by the B o a r d ' s i n v e s t i g a t o r s to A m e r i c a n
A i r l i n e s ' Overhaul and Supply Depot a t T u l s a
f o r I n o r e detailed examination. At T u l s a the
r i g h t engine, landlng g r a r , and a s s o c i a t e d wing
structure were assembled in approximately
t h e i r r e l a t i v e flight positions for the purpose of
t r a c i n g the f i r e path. F i r e originated in zone l *

*) Zone 1 - Engine power s e c t i o n ; zone 2 - accessory section; z,one 3 - a f t of the firew'ill.

 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
between Nos. 11 and 13 c y l i n d e r s and p r o g r e s s e d
directly r e a r w a r d into zone 2 a t the d i a p h r a g m
outer edge s e a l . The p a t t e r n of heaviest f i r e
damage extended d i r e c t l y back f r o m No. 12 cyl-
inder. F i r e p a s s e d out of zone 2 f o r w a r d of the
firewall a t the mating s u r f a c e s of the lower and
inboard cowls, and of the lower and outboard
cowls. I t e n t e r e d zone 3 immediately aft of the
firewall on the inboard side of the nacelle,
Burned-through fuel, hydraulic, and cabin com-
p r e s s o r oil lines i n zone 3 r e l e a s e d combusti-
b l e s , and f i r e of i n c r e a s e d intensity p r o g r e s -
s e d r e a r w a r d along the inboard side of the na-
c e l l e t o the front s p a r . The upper and lower
r a i l s and web of the f r o n t s p a r w e r e heated t o
the point where m a t e r i a l was weakened and the
lower r a i l failed i n tension, resulting i n s e p a -
ration of the right wing f r o m the a i r c r a f t .
Impact and f i r e damage was such that
the condition of the f i r e s e a l between z o n e s 1
and 2 p r i o r to the accident could not be d e t e r -
mined. Effective sealing i n this a r e a depends
on contact betweeq a neoprene a s b e s t o s s e a l
attached t o the p e r i p h e r y of the d i a p h r a g m and
the inner s u r f a c e of the orange peel cowl.
After the accident the c a r r i e r o r d e r e d
a n inspection of i t s Convair fleet t o d e t e r m i n e
if specific undesirable conditions existed with
r e s p e c t t o this f i r e s e a l , and c o r r e c t i v e action
was taken in a l l c a s e s where such conditions
w e r e found. Seals a r e now being renewed eve-
r y overhaul instead of upon condition o r approx-
imately e v e r y other overhaul, a s was done p r e -
viously. In addition, a chalk t e s t is being made
upon installation t o d e t e r m i n e m o r e conclusive-
ly if t h e r e i s p r o p e r mating between the dia-
p h r a g m and the o r a n g e p e e l cowl.
In 1952 A m e r i c a n Airlines modified the
f i r e detector sybtem in a l l of i t s Convair 240's
for the purpose of obtaining quicker f i r e warn-
ings. This modification was worked out with
the manufacturer and i b essentially the s a m e a s
the s y s t e m that i s s t a n d a r d on the Convdir
340's. A single light in the cockpit shows the
c r e w which powerplant a f i r e i s in but does not
indicate the zone. E m e r g e n c y p r o c e d u r e s a r e
t o be initiated by the c r e w a s soon a s a f i r e
warning i s received. These include actuating
the extinguishing s y s t e m , which d i s c h a r g e s in
zones 2 and 3 orly.
During the investigation of this accident
i t was not possible to make a functional check
of the f i r e detector s y s t e m f o r the r i g h t engine
and nacelle because of e x t r e m e f i r e and i m p a c t
damage. Also, the f i r e extinguisher control
panel in the cockpit was s o damaged that no
161
information pertinent t o the accident could be
obtained f r o m it. All C 0 2 bottles w e r e recov-
e r e d , however, with t h e i r heads, including the
t h e r m a l d i s c s , intact, a n d when weighed w e r e
found to be empty. The C 0 2 retention door i n
the zone 2 chimney was found closed.
Control linkages t o the right s i d e f i r e -
wall shutoff valves w e r e b r o k e n and detached,
and the valves showed i m p a c t and f i r e d a m a g e .
The engine oil, cabin c o m p r e s s o r oil, and hy-
d r a u l i c fluid valves w e r e found closed; the fuel
shutoff valve was s o damaged that its position
could not be d e t e r m i n e d . All of the f i r e w a l l
shutoff v l l v e s , however, a r e mechanically
linked t o one common control handle.
The e l e c t r i c a l l y o p e r a t e d r i g h t m a i n
tank fuel shutoff valve, located i n zone 3, w a s
r e c o v e r e d i n the open position; a l l wiring had
been burned f r o m i t s e l e c t r i c a l connector.
After p r e l i m i n a r y examinationat T u l s a t h e
No. 12 cylinder, piston, piston pin, and link
rod w e r e s e n t t o the National B u r e a u of Stand-
a r d s f o r l a b o r a t o r y study. T h i s study r e v e a l e d
that s e v e r a l fatigue c r a c k s , s t a r t i n g a t t h e out-
side s u r f a c e of the cylinder wall, h a d joined to
f o r m a single l a r g e c r a c k t h a t extended around
approximately one-third of the c i r c u m f e r e n c e
before the cylinder failed completely, It did
not r e v e a l any a b n o r m a l i t i e s i n the composition
o r m i c r o s t r u c t u r e of the s t e e l that could have
contributed t o the c a u s e of f a i l u r e . F r a c t u r e s
on the link rod and piston a p p e a r e d to be second-
a r y ones c a u s e d by s t r e s s e s above the yield
s t r e n g t h of the m a t e r i a l .
A review of the h i s t o r y of the failed
cylinder disclosed that i t was installed new i n
the No. 18 location on another engine in October
1954 and had o p e r a t e d t h e r e for approximately
1052 h o u r s when eight of i t s hold-down s t u d s
failed, seven of which w e r e adjacent t o e a c h
o t h e r . T h e s e failed studs were found during
a n inspection a t Detroit, following which the
engine was removed f r o m the a i r c r a f t and s e n t
i n t o A m e r i c a n ' s overhaul b a s e a t T u l s a . At
the t i m e the cylinder was removed i n engine
d i s a s s e m b l y a t the overhaul b a s e a s p e c i a l cyl-
inder stud f a i l u r e f o r m r e q u i r e d by A m e r i c a n
w a s made out f o r the engineering d e p a r t m e n t ,
and a notatidn was m a d e on t h e front s h e e t of
the engine inspection log that eight of t h e hold-
down s t u d s f o r this cylinder had failed. On
another page of this s a m e log the cylinder w a s
m a r k e d a s " 0 , K. " by inspection. The next
r e c o r d of t h i s cylinder was a n inspection c a r d
showing a n inside and outside inspection with
no indication of whether a check had b e e n made
for warpage of the flange.
162 ICAO C i r c u l a r 5 0 - ~ N / 4 5
0

T h r e e d a y s a f t e r this cylinder w a s r e - u s e of a s u r f a c e plate and f e e l e r gauge. If t h e r e

moved f r o m the engine in which t h e stud fail- w a s warpage of .005 inch o r l e s s , the cylinder
u r e s had o c c u r r e d i t w a s put b a c k in s e r v i c e in w a s to be lapped; if t h e r e w a s warpage in e x c e s s
the No. 1 2 location on another engine undergo- of that amount the cylinder w a s t o b e r e b a r r e l e d .
ing overhaul a t the T u l s a b a s e . When the a i r - Company personnel testified that t h i s method of
c r a f t involved in this accident a r r i v e d a t Tulsa inspection had not been followed for s o m e t i m e
f o r a p a t t e r n 1 overhaul (conducted by A m e r i - and that flanges w e r e checked v i s u a l l y instead.
can e v e r y 2 100 h o u r s of operation), this engine They s a i d they considered this visual check suf-
was i n s t a l l e d a s a r e p l a c e m e n t f o r t h e No. 2 ficient u n l e s s a n a b n o r m a l w e a r p a t t e r n w a s
engine removed f r o m the a i r c r a f t . The a i r c r a f t evident, in which c a s e the p r o c e d u r e called f o r
was t e s t flown and r e l e a s e d for s e r v i c e on 3 in the manual was followed. An inspector t e s -
August; the cylinder failed on 4 August a f t e r tified that this p a r t i c u l a r technique was "handed
slightly l e s s than six h o u r s of operation. down" t o him by the m o r e experienced i n s p e c t o r
who t r a i n e d him for this operation.
During the check on t h e h i s t o r y of this
cylinder s e v e r a l d i s c r e p a n c i e s w e r e noted in S u p e r v i s o r y and engineering p e r s o n n e l
the c a r r i e r ' s engine overhaul r e c o r d s . One of of the company testified that based on e x p e r i -
t h e s e was showing c y l i n d e r s being r e m o v e d ence they c o n s i d e r e d t h i s v i s u a l inspection t o
f r o m t h e r e a r r o w and r e i n s t a l l e d on the front be equivalent to the p r o c e d u r e specified in their
row, which i s a n impossibility. I t w a s testified overhaul manual and r e c o m m e n d by the manu-
t h a t t h e s e w e r e c l e r i c a l e r r o r s ; t h a t the p r i m a - f a c t u r e r , and that o m i s s i o n of the f e e l e r gauge
r y purpose of the r e c o r d s was t o maintain h i s - check by inspection was with t h e knowledge and
t o r i c a l data on the u s e of p a r t s and they w e r e c o n c u r r e n c e of the engineering department.
not used a s a c r o s s check t o help i n s u r e that
unairworthy p a r t s w e r e not r e t u r n e d to s e r v i c e . T h e r e w e r e n o written instructions con-
cerning this r e v i s e d p r o c e d u r e a n d the Civil
A m e r i c a n A i r l i n e s ' p r o c e d u r e s provided Aeronautics Administration had not been i n -
t h a t any cylinder which had been o p e r a t e d with f o r m e d of it.' CAA maintenance agents a s s i g n -
m o r e than two adjacent hold-down s t u d s broken ed to A m e r i c a n A i r l ~ n e s 's y s t e m maintenance
o r the nuts loose should b e s c r a p p e d o r r e t u r n - a t Tulsa testified that the operations t h e r e a r e
ed to t h e manufacturer f o r r e b a r r e l i n g . Such a under constant s u r v e i l l a n c e and that in addition
cylinder was t o be tagged in engine d i s a s s e m b l y to daily contacts a g e n e r a l inspection i s run
t o a l e r t inspection t h a t t h e cylinder was to have e v e r y s i x months, t h e l a s t one being approxi -
s p e c i a l handling. F o r this p u r p o s e a blank alu- rnately two months p r i o r to the accident. They
minum tag, approximately one-half inch wide a l l testified, however, that they w e r e not a w a r e
and two inches long, was affixed to the cylinder of the r e v i s e d p r o c e d u r e for inspecting cylinder
with the s a m e m e t a l safety pin that c a r r i e d b a r r e l flanges. No one s e e m e d t o know exactly
another and l a r g e r tag bearing the s e r i a l number when this p r o c e d u r e was put into effect but i t
of the engine f r o m which the cylinder had been was e s t i m a t e d by an A m e r i c a n A i r l i n e s official
removed. Inspection decided whether the cyl- to have been the l a t t e r p a r t of 1953. Engineer-
inder should b e s c r a p p e d o r r e b a r r e l e d . ing p e r s o n n e l a l s o t e s t ~ f i e dthat a cylinder op-
vrated with approximately one-half of i t s studs
A m e r i c a n A i r l i n e s ' overhaul manual broken o r the hold-down stud nuts l o o s e would
specified and the engine m a n u f a c t u r e r r e c o m - chow a w e a r pattern obvious t o \,isual inspection,
mended that the flanges of a l l cylinders going and that t h e r e would be definite warpage of the
through overhaul be inspected f o r f l a t n e s s by flange.

* CAR P a r t 40.50 - P r e p a r a t i o n of manual. The a i r c a r r i e r s h a l l p r e p a r e and keep c u r r e n t a

manual f o r the u s e and guidance of flight and ground operations personnel in the conduct of i t s
operations.

CAR P a r t 40.52 - Distribution of manual. (a) Copies of t h e e n t i r e manual, o r a p p r o p r i a t e

portions thereof, together with revisions t h e r e t o s h a l l b e furnished to t h e following: (1) Appro-
pricite ground operations and maintenance personnel of the a i r c a r r i e r , ( 2 ) Flight c r e w m e m b e r s ,
( 3 ) Authorized rcpresent,:tives of the Adwinistrator assigned to the a i r c a r r i e r t o a c t a s avia-
tiun safety agents. (b) All copie4 of the ~ n a n u a l,hall be kept up t o date.

CAI< P d r t 18. 30 - Stdnti'ird of p e r f o r n ~ n n c e , generdl. A l l r n a i n t e n a n ~ e , r e p d i r s , and a l t e r a -

t i < , ~ l 211a11
s - d ;I< ro!-dciiitr with rriethods, tecl~nicjues,d r ~ dp r u c t l c z s approved
b e , ~ c c o r n p l i s l ~ tIn
by o r ' r c c . ~ p t , t t ~to
l e thc Ac!rrlini~tr~rtor.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 163

A P r a t t & Whitney r e p r e s e n t a t i v e t e s t i - of the blank m e t a l tag could have been omitted;

fied that h i s company Is recommendation concern- (2) cleaning, where t h e a l e r t tag could have
ing inspection of flanges for flatness applied to been l o s t f r o m the cylinder ( t h e r e w a s t e s t i m o -
a l l c y l i n d e r s going through overhaul and that a ny that considerable difficulty had been e x p e r i -
visual check could not be considered equivalent enced f o r s o m e t i m e with aluminum t a g s being
to the p r e c i s e m e a s u r e m e n t obtained through mutilated o r l o s t i n the cleaning p r o c e s s , and
use of the s u r f a c e plate and f e e l e r gauge. He the c a r r i e r was experimenting with the u s e of
s t a t e d f u r t h e r t h a t i n m o s t c a s e s warpage and b r a s s t a g s i n a n effort t o c o r r e c t the difficulty);
a peculiar w e a r p a t t e r n on the flange would r e - and (3) inspection, where the a l e r t t a g could
s u l t f r o m operation with loose hold-down nuts have been overlooked.
o r broken s t u d s , t h e amount being dependent on
the length of s u c h operation. Shortly a f t e r the accident A m e r i c a n
A i r l i n e s initiated a s e r i e s of changes i n o v e r -
In-service failure of cylinder b a r r e l s haul p r o c e d u r e s and i n personnel a s s i g n m e n t s ,
h a s b e e n c o r r e l a t e d with operation with b r o k e n a l l pointed toward m o r e s t r i n g e n t s u p e r v i s o r y
studs and/or loose hold-down nuts. After the control of work done. The change m o s t d i r e c t -
accident P r a t t & Whitney reproduced the failure ly concerned with this accident involves the
on a t e s t stand by simulating, on a new cylinder, handling of c y l i n d e r s going through overhaul.
failure of the s a m e s t u d s in operation, followed C y l i n d e r s that had b e e n o p e r a t e d with loose hold-
by operation of the cylinder with a l l studs s e - down nuts o r broken studs now have t h e i r b a r r e l s
c u r e and the hold-down nuts p r o p e r l y torqued. mutilated a s soon a s they a r e r e m o v e d f r o m a n
A fatigue c r a c k developed on the outside of the engine, thus making i t impossible f o r t h e m t o be
cylinder b a r r e l a f t e r t h r e e h o u r s of operation r e t u r n e d t o s e r v i c e without f i r s t being r e b a r -
a t take-off power with the studs s e c u r e . A r e l e d . Such mutilation i s witnessed by a t l e a s t
check before the hold-down nuts w e r e tightened one o t h e r p e r s o n . F u r t h e r , the check of a l l cyl-
showed .0085 inch warpage of the flange. inder b a r r e l flanges by m e a n s of the s u r f a c e
plate and f e e l e r gauge h a s b e e n r e s u m e d , and
A check of r e c o r d s a f t e r the accident r e - the warpage t o l e r a n c e h a s been reduced f r o m
vealed that 23 o t h e r c y l i n d e r s operated with b r o - . 0 0 5 ;to . 0 0 3 inch i n a c c o r d a n c e with a r e c o m -
ken studs and/or loose hold-down nuts had been mendation i s s u e d by the m a n u f a c t u r e r a f t e r t h e
p a s s e d by inspection and r e t u r n e d to s e r v i c e accident.
without being r e b a r r e l e d . They w e r e immedi-
a t e l y removed f r o m the engines on which they F a i l u r e of the cylinder w a s accompanied
had been installed, One of the 23, which had by the r e l e a s e of combustibles consisting of a
experienced a four-stud f a i l u r e , was installed fuel-air m i x t u r e f r o m the d i s r u p t e d intake pipe
in the No. 16 location of the engine involved in and oil f r o m t h e c r a n k c a s e section. The m o s t
this accident. It was m a r k e d " 0 . K . i n the likely s o u r c e of ignition w a s the exhaust mani-
inspection log. fold which is routed r e a r w a r d of the c y l i n d e r s .
Sixteen of t h e s e c y l i n d e r s , plus two oth- No. 12 cylinder s t r a d d l e s the mating
e r s that w e r e i n the overhaul shop but not yet line of the lower and inboard s i d e orange p e e l
installed on engines, w e r e s e n t by A m e r i c a n cowls. After the cylinder failed f i r e p a s s e d
A i r l i n e s t o P r a t t & Whitney for examination. r e a r w a r d into zone 2 a t the lower left c o r n e r of
P r a t t & Whitney's r e p o r t showed that the flanges t h e d i a p h r a g m , which i s a f t of No. 1 2 cylinder.
of eleven of t h e m w e r e "fretted and galledv1;two It is believed that f i r e p r o g r e s s e d into zone 2
w e r e "severely fretted"; and one other showed quite rapidly. The f i r e path i n that zone is i n
"heavy fretting and galling. T h i s l a t t e r cylin- a c c o r d with the zone 2 a i r flow p a t t e r n and the
d e r , removed f r o m a n engine with no operating location of original e n t r y of f i r e into zone 2.
t i m e since overhaul, showed c r a c k indications More significant i s the exit of f i r e f r o m zone 2,
when magnetically Inspected. One of the cylin- which o c c u r r e d a t the mating line between the
d e r s , on which eight studs had failed, showed lower cowl and both s i d e cowls a t and behind the
flange warpage of .006 inch; flange warpage in r e a r m o s t f a s t e n e r s . F i r e on the inboard s i d e
the o t h e r s varied f r o m .0015 inch t o .0035 Inch. burned the aluminum nacelle skin back of the
firewall and between the upper and lower nacelle
A m e r i c a n Airllnes oftlcials testified that longerons, permitting f i r e entry into zone 3 .
despite a n intensive effort to d e t e r m i n e where a
breakdown o c c u r r e d that permitted such cylin- The c r e w m u s t have become a w a r e of
d e r s to be put back in s e r v i c e , they had not been the engine difficulty and initiated e m e r g e n c y
able to pinpoint i t c l o s e r than one of t h r e e loca- p r o c e d u r e s a t once. Relatively m i n o r damage
tions: (1) engine d i s a s s e m b l y , where affixing t o the No. 1 2 link r o d , which was f r e e to flail
164 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5

a f t e r the cylinder l e t go, indicates a n a l m o s t existing difficulty with the m e t a l a l e r t t a g s

i m m e d i a t e feathering of the p r o p e l l e r . T h i s should have e m p h a s i z e d the i m p o r t a n c e of r i g i d
would h a l t the r e l e a s e of c o m b u s t i b l e s i n zone 1 inspection to avoid the possibility of p a s s i n g
and account f o r the c o m p a r a t i v e l y light f i r e d a m - faulty c y l i n d e r s . F r o m the f a c t that c y l i n d e r s
a g e in t h a t a r e a . which should have been r e j e c t e d w e r e r e t u r n e d
t o s e r v i c e i n s t e a d , i t i s obvious that visual in-
That CO w a s d i s c h a r g e d in flight i s spection a l o n e , dependent on the judgment and
evidenced by the f a c t that a l l CO2 bottles w e r e evaluation of an individual, i s inadequate. Af-
found empty with t h e i r heads, including the t h e r - t e r the accident A m e r i c a n A i r l i n e s w a s able
m a l d i s c s , intact. It i s , t h e r e f o r e , r e a s o n a b l e f r o m i t s r e c o r d s t o locate these c y l i n d e r s and
t o a s s u m e t h a t the f i r e extinguishing s y s t e m w a s r e m o v e t h e m f r o m S e r v i c e . However, p r i o r t o
actuated a t the t i m e c a l l e d f o r i n the e m e r g e n c y t h a t t i m e no use was m a d e of the r e c o r d s a s a
procedure checklist. c r o s s c h e c k to p r e v e n t the installation of cyl-
i n d e r s that should have been r e j e c t e d by in-
The e m e r g e n c y p r o c e d u r e f o r inflight spection.
f i r e c o n s i s t s of two p h a s e s , the second p a r t
being a "cleanuptt l i s t of i t e m s c o n s i d e r e d l e s s P r a t t & Whitney's recommendation t h a t
urgent than those d i r e c t l y r e l a t e d t o controlling the b a r r e l flanges of c y l i n d e r s going through
and putting out t h e f i r e . One of t h e i t e m s n e a r overhaul be checked by use of a s u r f a c e plate
the end of this l i s t i s t o c l o s e the m a i n fuel tank a n d f e e l e r gauge points up the inadequacy of v i s -
shutoff valve. C o n s t r u c t i o n of this valve, which ual inspection. The B o a r d i s of the opinion t h a t
was found open, p r e c l u d e s any likelihood of i t s had t h e method of inspection specified in t h e c a r -
position being changed b e c a u s e of i m p a c t f o r c e s . r i e r ' s overhaul m a n u a l and r e c o m m e n d e d by
T h e r e i s no way of d e t e r m i n i n g whether the c r e w the m a n u f a c t u r e r been followed, c y l i n d e r s with
did not r e a c h this i t e m on the c h e c k l i s t o r wheth- warped b a r r e l f l a n g e s could not have been r e -
e r by the t i m e they a t t e m p t e d t o c l o s e the valve t u r n e d t o s e r v i c e inadvertently. The Board
i t s e l e c t r i c a l wiring had b e e n s o d a m a g e d by f e e l s that the c a r r i e r should have informed the
f i r e t h a t it was no longer operable. T h e l a t t e r C i v i l A e r o n a u t i c s A d m i n i s t r a t i o n of the r e v i s e d
s e e m s the m o r e likely of the two. T h i s valve p r o c e d u r e f o r inspecting cylinder b a r r e l flanges
r e m a i n i n g open unquestionably contributed t o t h e i n o r d e r t o d e t e r m i n e whether i t w a s acceptable
intensity and duration of f i r e i n zone 3 s i n c e it t o the A d m i n i s t r a t o r . However, it i s difficult
p e r m i t t e d gasoline t o b e r e l e a s e d a t a n a p p r e c i - t o understand why, in t h e i r routine inspections,
a b l e r a t e . The B o a r d is of t h e opinion that con- the CAA a g e n t s did not b e c o m e a w a r e that for
s i d e r a t i o n should be given t o making the closing a period of n e a r l y two y e a r s s u c h flanges w e r e
of this valve one of the f i r s t of the I1cleanuptt not being i n s p e c t e d i n a c c o r d a n c e with the c a r -
i t e m s called f o r i n e m e r g e n c y p r o c e d u r e s t o be r i e r ' s overhaul manual.
followed i n the event of f i r e warning.
Following this accident A m e r i c a n A i r -
R a d a r t r a c k i n g of the a i r c r a f t showed line s took i m m e d i a t e c o r r e c t i v e a c t i o n with
a change of c o u r s e t o the r i g h t approximately r e s p e c t to i t s cylinder and f i r e s e a l overhaul
17-1/2 nautical m i l e s f r o m F o r n e y F i e l d , which and inspection p r o c e d u r e s . As previously s t a t -
was probably when the d e c i s i o n was m a d e t o e d i n t h i s r e p o r t , the b a r r e l s of c y l i n d e r s op-
a t t e m p t a n e m e r g e n c y landing t h e r e . Inasmuch e r a t e d with loose hold-down nuts and/or b r o k e n
a s the zone 3 f i r e w a s not visible f r o m the cock- s t u d s a r e now being m u t i l a t e d upon r e m o v a l
pit, the pilots could not have b e e n a w a r e of i t s f r o m a n engine t o preclude the possibility of
e x t r e m e severity. Had they been able t o r e c o g - t h e i r being r e t u r n e d to s e r v i c e without r e b a r -
nize the proximity of f i r e t o the wing s p a r they r e l i n g . New f i r e s e a l s a r e being i n s t a l l e d a t
undoubtedly would have t r i e d t o land i m m e d i a t e - e v e r y overhaul and a m o r e positive check i s
l y , r e g a r d l e s s of the f a c i l i t i e s available. being m a d e t o e n s u r e t h e effectiveness of the
seal.
The B o a r d h a s given m u c h c o n s i d e r a -
tion t o t h e evidence i n a n effort t o d e t e r m i n e The a i r c r a f t m a n u f a c t u r e r a l s o initiated
just how a n unairworthy cylinder could have been a Program the f i r e protec-
put back i n s e r v i c e a t the c a r r i e r ' s overhaul tion i n a l l Convair a i r c r a f t , and will i s s u e S e r v -
b a s e . I f , a s t e s t i f i e d , a w e a r p a t t e r n caused by ice Bulletins these a s they
operation of c y l i n d e r s with b r o k e n s t u d s o r loose a r e
hold-down nuts would be evident t o v i s u a l in- Probable Cause
spection, t h e r e s e e m s no logical r e a s o n why
this and o t h e r c y l i n d e r s s o o p e r a t e d w e r e p a s s e d The probable c a u s e of this accident w a s
by inspection r e g a r d l e s s of whether the a l e r t tag installation of a n unairworthy c y l i n d e r , the
was on the cylinder when i t r e a c h e d the in- f a i l u r e of which r e s u l t e d in a n uncontrollable
spection station. In addition, the r e p o r t e d long- f i r e and subsequent l o s s of a wing in flight.

ICAO Ref: ~ ~ / 4 0 2
Frgtira: cll W i d e World Pluota
 166 ICAO C i r c u l a r 5 0 - ~ N / 4 5
No. 37
Northwest A i r l i n e s , Inc., Boeing 377 a i r c r a f t , o v e r s h o t runway on landing
a t Chicago Midway A i r p o r t , Illinois, on 5 August 1955. Civil Aeronautics B o a r d (USA)
Accident Investigation Report F i l e No. 1-0091, r e l e a s e d 9 J a n u a r y 1956.
Circumstances
The flight originated a t Minneapolis,
Minnesota, with i t s destination Chicago,
Illinois. It d e p a r t e d Minneapolis - St. P a u l
International A i r p o r t a t 11 30 C e n t r a l Standard
T i m e o n a n Instrument Flight Rules flight
plan c a r r y i n g 60 p a s s e n g e r s and a c r e w of 8.
When the flight r e p o r t e d o v e r Janesville, Wis-
consin, an ARTC ( A i r Route Traffic Center)
c l e a r a n c e was received to descend and c r o s s
the Wilson Intersection (15 m i l e s NNW of
Chicago Midway) a t 3 500 feet. The IFR c l e a r -
a n c e was cancelled by the pilot s h o r t l y a f t e r
passing Wilson Intersection. At 1256 radio
frequency w a s changed to Midway tower and
t h e flight was then advised to r e p o r t west of
the field f o r a left t u r n f o r landing on Runway
31L. Touchdown was about one-quarter down
the runway, and the landing r o l l continued to
t h e end of the runway without appreciable de-
celeration. At the end of the runway a slight
t u r n to the left was made and the a i r c r a f t cross-
e d s e v e r a l hundred f e e t of g r a s s y a r e a before
c r a s h i n g through the chain link fence bordering
the a i r p o r t . Although the a i r c r a f t was substan-
tially damaged, no i n j u r i e s w e r e received by
the p a s s e n g e r s o r c r e w .
Investigation and Evidence
The a i r p o r t weather a t the t i m e of the
accident was:
Ceiling 10 000 feet, broken clouds,
o v e r c a s t a t 25 000 feet; visibility
10 m i l e s ; wind w e s t 8 knots. During
the period 1000 to 1300 t h e r e had
been intermittent light r a i n s h o w e r s
(. 01 inch); however, the runway s u r -
face w a s d r y a t the time the flight
landed.
It w a s determined that a touchdown had
been made in the intersection of Runways 31L
and 36R. T h i s location is approximately 1 600
f e e t beyond the approach end of Runway 31L,
which is 6 410 f e e t long. The f i r s t d i s c e r n i b l e
braking m a r k s of the a i r c r a f t on the runway
w e r e approximately 3 000 f e e t beyond the point
of touchdown. T h e s e m a r k s w e r e light i n
c h a r a c t e r and extended o n the runway f o r
approximately 600 feet. The next 800 feet of
m a r k s reflected light to f a i r braking action,
and the final 300 f e e t of m a r k s a t the end of
Runway 31L indicated heavy braking action, a s
did the m a r k s a c r o s s the 300 f e e t of g r a s s y
a r e a leading to the boundary fence.
According to the testimony of the c r e w ,
a i r s p e e d a t touchdown was approximately 95
knots. Following touchdown b r a k e s w e r e applied
lightly. When the t h r o t t l e s w e r e moved into the
r e v e r s e quadrant, f o r w a r d t h r u s t w a s expe-
rienced. When this o c c u r r e d the captain put
the throttles into the f o r w a r d idle position,
called f o r antiskid ( a device designed to p r e v e n t
locking of the wheels) off, and a f t e r getting no
deceleration f r o m use of the n o r m a l b r a k e s
used full and continuous application of the e m e r -
gency system. The captain s t a t e d t h a t he turn-
ed the a i r c r a f t t o the left a t the end of the run-
way to avoid striking the l a r g e c o n c r e t e m a r k e r
just off the end of Runway 31L. All c r e w m e m -
b e r s s t a t e d t h e r e was no indication of p r o p e l l e r
r e v e r s a l a t any time during the landing roll.
T h i s absence of the noise and d e c e l e r a t i o n
accompanying p r o p e l l e r r e v e r s i n g i s substan-
tiated by many p a s s e n g e r s and ground witnesses.
The captain testified that he felt t h a t t h e r e w a s
sufficient runway remaining a f t e r the unsuccess-
ful p r o p e l l e r r e v e r s a l a t t e m p t to stop the a i r -
c r a f t with braking. He f u r t h e r s t a t e d that he
h a s had incidents a t Midway A i r p o r t of slippery
runways not due t o snow, i c e , o r rain.
The s u r f a c e of Runway 31L is asphalt
with a topping of c r u s h e d rock screenings. At
the t i m e of the accident the c r u s h e d rock cover-
ing was m o r e i n evidence n e a r the ends than i n
the middle a r e a of this much-used runway.
When t e m p e r a t u r e s a r e above 90°F. the asphalt
exudes a n oily substance that c r e a t e s a slippery
surface. T e m p e r a t u r e a t the ,time of the a c c i -
dent was 850F. and the runway was f r e e of mois-
t u r e . Although Midway tower had r e c e i v e d no
pilot r e p o r t s of poor braking action on the day
of the accident, c o n t r o l l e r s stated t h e r e had
been i n s t a n c e s of pilots reporting poor braking
when t e m p e r a t u r e s w e r e high and the runway
w a s f r e e of moisture.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
T h e flight manual f o r B-377 a i r c r a f t In-
d i c a t e s that with a g r o s s load of 110 000 pounds
(the approximate landing weight at Chicago of
t h i s flight), head wind of 8 knots and t e m p e r -
a t u r e of 85 d e g r e e s , the a i r c r a f t should s t o p
in 3 400 f e e t when landing o v e r a 50-foot Ob-
s t a c l e using n o r m a l braklng, and without the
u s e of p r o p e l l e r r e v e r s i n g . The m i n i m u m
runway length under these conditions i s 5 700
feet.
A m a j o r i t y of the blades of a l l f o u r p r o -
p e l l e r s w e r e damaged by contact with thefence.
The No. 3 engine mount w a s damaged to an
extent requiring r e p l a c e m e n t of the power-
plant. The four t i r e s of the m a i n g e a r indi-
cated heavy braking action, a s evidenced by
l a r g e abraded a r e a s extending a l m o s t through
the casing. The wing f l a p s and the nose g e a r
received damage f r o m contact with the fence.
The left side of the fuselage was sliced open
f r o m the top down to the " c r e a s e " line by the
whirling of the s t e e l fencing w h ~ c hb e c a m e
entangled in t h e p r o p e l l e r s a s the a i r c r a f t
p a s s e d through the fence. The right side of
the fuselage received l e s s e r damage i n the
s a m e manner. Contact with a s t r e e t lighting
pole indented the o u t e r leading edge of the left
wing.
Cockpit readings taken immediately a f t e r applications of e m e r g e n c y b r a k e s , a thorough
the accident revealed, among many o t h e r items, engine runup w a s m a d e , during which a check
the following: Normal b r a k e s y s t e m p r e s s u r e
1 500 p. s. i . ; emergency brake s y s t e m p r e s -
s u r e 1 500 p. s . i . ; antiskid m a s t e r switch "off':
the r e v e r s i n g control looutboard and inboardi1
c i r c u i t b r e a k e r s on the overhead panel in the
"out" position. All other c i r c u i t b r e a k e r s on
t h i s panel w e r e "ing1.
The deadheading flight engineer, who
had no a s s i g n e d duties on the flight, was in
the o b s e r v e r ' s s e a t behind the captain a t the
t i m e of the landing. On h i s own initiative he
pulled and immediately r e s e t the oleo r e l a y
c i r c u i t b r e a k e r a f t e r the captain had t r i e d un- r e v e r s e quadrant. F o r w a r d t h r u s t is obtained
successfully to obtain p r o p e l l e r r e v e r s i n g .
The action of the deadheading flight engineer
in pulling out and r e s e t t i n g the oleo r e l a y c i r -
cuit b r e a k e r a f t e r the one r e v e r s a l attempt
w a s a n unrequested check on h i s p a r t to e n s u r e i n the r e v e r s e range.
a good contact of t h i s c i r c u i t b r e a k e r in the
event that p r o p e l l e r r e v e r s a l w a s again attempt-
ed. According to testimony of the c r e w m e m -
b e r s , t h i s was the only c i r c u i t b r e a k e r on the
overhead panel moved during the e n t i r e flight.
The overhead panel i s located in the f o r -
ward p a r t of the cockpit ceiling between and
slightly to the r e a r of the two pilot s e a t s , and
167
~ r n m e d i d t e l yabove and ahead of the flight
e n g i n e e r ' s s e a t . Dimensions of the panel a r e
approximately 3 6 inches f o r e and aft and 18
inches wide. The f o r w a r d half contains the
engine ignition switches, feathering buttons,
v a r i o u s engine operation and a i r c r a f t lighting
switches. The r e a r half of the panel h a s five
spanwise rows of approximately 25 c i r c u i t
b r e a k e r s each. The oleo r e l a y c i r c u i t b r e a k e r
i s located in the r e a r row eighth f r o m the left
s i d e and the two r e v e r s i n g control c i r c u i t
b r e a k e r s a r e located in the fourth row, f r o m
the r e a r , a t the approximate c e n t e r of the row.
The two antiskid c i r c u i t b r e a k e r s a r e i m m e -
diately a f t of the p r o p e l l e r r e v e r s i n g c o n t r o l
c i r c u i t b r e a k e r s . All c i r c u i t b r e a k e r s c a n be
r e a c h e d f r o m any of the t h r e e c r e w s e a t s .
Following the accident the a i r c r a f t was
removed t o a hangar on Midway A i r p o r t . S t r u c -
t u r a l r e p a i r s w e r e made and No. 3 powerplant
w a s r e p l a c e d before actual testing of the braking
and p r o p e l l e r r e v e r s i n g s y s t e m s . On 19 August
functional t e s t s of these units w e r e p e r f o r m e d
at Midway Airport. A p r e l i m i n a r y group run-
up included the following checks: Magneto, pro-
p e l l e r r e v e r s i n g , and manual feathering, No
d i s c r e p a n c i e s w e r e noted and the a i r c r a f t was
then turned o v e r to the flight t e s t c r e w . After
taxying, in which t h e r e w e r e s e v e r a l effective
was made of auto-feathering, manual f edther -
ing, and p r o p e l l e r r e v e r s i n g with n o r m a l r e s u l t s .
The two r e v e r s i n g control c i r c u i t b r e a k -
e r s were then pulled and a check w a s made of
engine r a p . m. i n the f o r w a r d idle and r e v e r s e
idle throttle positions. T h i s t e s t revealed the
r e v e r s e idle r. p. m. t o be f r o m 300 to 500 high-
e r than f o r w a r d idle r . p . m . on a l l engines.
The captain and f i r s t officer s t a t e d t h a t
f o r w a r d t h r u s t w a s experienced when the
t h r o t t l e s w e r e moved p a s t the detent into the
when the t h r o t t l e s a r e moved into the r e v e r s e
quadrant if the r e v e r s i n g control c i r c u i t break-
e r s a r e 'toutJ' a t t h e s t a r t of the throttle move-
ment and r e m a i n llout" while the t h r o t t l e s a r e
Threie a c c e l e r a t e d stop-runs w e r e m a d e
i n which the a i r c r a f t speed reached was 70-80
knots. During the f i r s t r u n n o r m a l b r a k e s w e r e
used with the antiskid f e a t u r e turned off; the
second r u n was with the antiskid on; the t h i r d
run used p r o p e l l e r r e v e r s i n g only. In a l l t h r e e
r u n s normal braking and decelercltion was
obtained.
168 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
Thorough checks w e r e made on the elec-
t r i c a l s y s t e m s and p r o p e l l e r d o m e s and no
malfunctioning was found.
The r e v e r s i n g control c i r c u i t b r e a k e r s '
being in the "out" position does not p r e v e n t
the moving of the t h r o t t l e s back into the r e -
v e r s e quadrant and the i n c r e a s e of engine
power in that position, but i t does deactivate
the p r o p e l l e r control c i r c u i t s a s s o c i a t e d with
r e v e r s i n g . T h u s the p r o p e l l e r blades would
r e m a i n i n f o r w a r d pitch producing f o r w a r d
t h r u s t . When the oleo r e l a y c i r c u i t b r e a k e r
i s "out" a throttle-locking solenoid p r e v e n t s
the t h r o t t l e s f r o m going r e a r w a r d p a s t the
throttle detent.
The Northwest Airlines Supervisor of
Flight E n g i n e e r s testified that this a i r c r a f t
had been used the day of the accident f o r a
captain's proficiency check and that he acted
a s flight engineer on that flight. He f u r t h e r
testified that during the landing r o l l of the l a s t
flight, one o r m o r e of the engines s t a r t e d to
d i e . As a c o r r e c t i v e action one, and possibly
both, of the p r o p e l l e r r e v e r s i n g control c i r -
cuit b r e a k e r s had been pulled and w e r e i n
t h i s position (off) when he left the a i r c r a f t a
s h o r t t i m e before the c r e w of the flight in
question took over.
It was explained that a number of inci-
dents had been experienced wherein p r o p e l l e r
blades moved to the feathered position when
coming out of r e v e r s e on landing, due to a
malfunction in the signal circuit.
Such an i n c r e a s e in blade angle i s a c -
companied by an i n c r e a s e in p r o p e l l e r load
that tends to s t a l l the engine. Meanwhile, the
a u x i l ~ a r ypump m o t o r t e m p e r a t u r e i n c r e a s e s
and the motor will burn out if e l e c t r i c a l power
i s not removed, Pulling out the a p p r o p r i a t e
c i r c u i t b r e a k e r r e s u l t s in shutting off the pump
which i n t u r n p e r m i t s the p r o p e l l e r blades to
move toward low pitch and the engine to r e g a i n
n o r m a l idle speed.
The flight engineer of the flight testified
that he had made a thorough preflight inspection
of this a i r c r a f t a t Minneapolis, including check-
ing the r e v e r s i n g control c i r c u i t b r e a k e r s f o r
"in" position. However, he could not r e c a l l
whether the check was made by actually touch-
ing the b r e a k e r s o r visually. He f u r t h e r t e s -
tified that he thought i t would be possible to
overlook a c i r c u i t b r e a k e r position in a visual
check.
T h e "checklist and p r o c e d u r e s " section
of Northwest A i r l i n e s Manual - Flight Opera-
tion - Boeing 377, l i s t s the i t e m s to be check-
e d by e a c h c r e w m e m b e r during a l l p r o c e d u r e s
f r o m "Before s t a r t " to "After landing" and
"Parking. " The manual d o e s not c a l l f o r a
mandatory p r o p e l l e r r e v e r s i n g check f o r p r e -
flight o n d o m e s t i c operations. The flight
engineer ground check l i s t s "Overhead c i r -
cuit b r e a k e r s - checked".
In the amplified flight e n g i n e e r ' s ground
check a r e listed i t e m s to be checked on o r i g -
inating a i r c r a f t . On page 10 in the "Aft Cock-
pit A r e a " p a r a g r a p h t h i s i t e m ( 7 ) a p p e a r s :
"Overhead c i r c u i t b r e a k e r s - CHECKED ( a )
a l l c i r c u i t b r e a k e r s IN o r ON".
T h e r e a r e no i t e m s covering a check of
the c i r c u i t b r e a k e r s o n the o v e r h e a d panel of
the cockpit a r e a during "Descent p r o c e d u r e , ' I
"Approach cockpit check, o r "Landing cockpit
check. "
The mdnual d o e s not specify how (i. e.
visually o r by touch) the c i r c u i t b r e a k e r s a r e
to be checked.
A s a r e s u l t of the subject accident North-
w e s t Airlines took action on 6 S e p t e m b e r 1955,
t o i n c o r p o r a t e in i t s flight o p e r a t i o n s manual
a check of overhead panel c i r c u i t b r e a k e r posi-
tion p r i o r to landing. In addition, i n s t r u c t i o n s
w e r e i s s u e d to flight i n s t r u c t o r and check p e r -
sonnel to p l a c e e m p h a s i s during periodic
training and check flights on the p r o p e r check-
ing of c i r c u i t b r e a k e r s .
The s e v e r e l y scuffed condition of the m a i n
landing g e a r t i r e s , o b s e r v e d a f t e r the accident,
p r o v e s that the n o r m a l e m e r g e n c y b r a k e sys-
t e m s had effectively stopped wheel rotation
and the m a r k s found on the runway indicate
that b r a k e s w e r e used during the l a t t e r p a r t
of the landing roll. The a c c e l e r a t e d stop-run
t e s t s conducted a t Chicago Midway A i r p o r t
showed that the b r a k e s y s t e m of the d i r c r a f t
w a s i n n o r m a l operating condition and that by
using t h e s e b r a k e s alone the a i r c r a f t could be
stopped in the required distance. It would
r e q u i r e approximately 20 seconds t o t r a v e l the
3 000 f e e t of runway between the touchdown and
the f i r s t braking m a r k s if a speed of some-
what l e s s than the touchdown speed of 95 knots
w a s maintained. During t h i s s h o r t i n t e r v a l
n o r m a l b r a k e s w e r e used while p r e p a r i n g to
go into reversing, the throttles w e r e moved i n
bnd out of the r e v e r s e quadrant, and the antiskid
 ICAO C i r c u l a r 50-AN/45
device was taken off. The sudden s u r p r i s e of
being confronted with lack of p r o p e l l e r r e -
versing and the ensuing cockpit activities un-
doubtedly w e r e the f a c t o r s which determined
where the emergency b r a k e s were applied.
T h e captain testified that he applied
emergency b r a k e s when halfway down the run-
way o r approximately 1 600 feet f r o m the point
of touchdown. Since no evidence of braking of
the a i r c r a f t was found in this a r e a i t a p p e a r s
that the friction coefficient of the runway s u r -
face was considerably l e s s during approxi-
mately 1 400 feet of the landing roll than i t
was where the f i r s t braking m a r k s w e r e ob-
served. It was e a r l y in the afternoon of a
w a r m day (85O) and the t e m p e r a t u r e may have
induced some slipperiness on the s u r f a c e of
the asphalt runway where the c r u s h e d rock
screenings were worn away. However, a i r -
c r a f t landing just before and just a f t e r the
accident did not r e p o r t such a condition.
Although the c r e w stated t h e r e was no
application of power during the e n t i r e landing
roll, a feeling of acceleration o c c u r r e d when
the throttles w e r e moved into the r e v e r s e
quadrant, The p r o p e l l e r s remained in forward
pitch in this instance and engine r . p . m. in-
c r e a s e s appreciably when throttles a r e moved
to the r e v e r s e idle position.
Thorough examination and t e s t s of the
p r o p e l l e r and e l e c t r i c a l s y s t e m s showed that
t h e s e s y s t e m s w e r e functioning in a n o r m a l
m a n n e r . Air c a r r i e r employees on Chicago
ICAO R e f : ~ ~ / 4 1 1
169
Midway Airport and tower c o n t r o l l e r s t e s -
tified that i t i s standard p r a c t i c e f o r o p e r a t o r s
of Boeing 377 a i r c r a f t to use propeller r e -
versing on a l l landings a t Chicago Midway Air-
p o r t . T h i s i s the p r a c t i c e even though the
lengths of the NW-SE a n d NE-SW runways,
which a r e always used f o r t h i s type a i r c r a f t ,
a r e i n e x c e s s of the c r i t e r i a specified f o r
braked stopping in the flight manual f o r B-377
a i r c r a f t . The captain testified that h e fully
intended to use r e v e r s i n g on the subject land-
ing.
Since the propeller r e v e r s i n g c i r c u i t
b r e a k e r s w e r e found i n the llout" position and
a s t h i s can be the only r e a s o n why p r o p e l l e r
r e v e r s i n g could not be effected in t h i s instance,
i t is apparent that they were not thoroughly
checked during the preflight check a t Minneapo-
l i s o r the prelanding check a t Chicago.
It was concluded that the "out" position
of the r e v e r s i n g control c i r c u i t b r e a k e r s was
the only r e a s o n to account f o r the captain's
inability t o obtain r e v e r s i n g when the t h r o t t l e s
w e r e moved into the r e v e r s e quadrant.
Probable Cause
The probable cause of the accident was
the inability of the pilot to stop the a i r c r a f t by
m e a n s of conventional braking and the unavail-
ability of propeller r e v e r s i n g due to the improp-
e r position of the r e v e r s i n g c i r c u i t b r e a k e r s .
170 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
No. 38
Civil Accident Report No. C. 637.
Circumstances
T h e accident o c c u r r e d during a pas-
s e n g e r c a r r y i n g flight f r o m J e r s e y A i r p o r t to
Blackbushe. The flight w a s uneventful until
the a l r c r a f t was approaching the south c o a s t
of the Isle of Wight when the s t a r b o a r d engine
began t o s u r g e and lose power. The pilot
decided to d i v e r t to Eastleigh but when o v e r
the Solent the p o r t engine a l s o l o s t power,
compelling him to ditch the a i r c r a f t . Of the
11 occupants on board the a i r c r a f t only 2 pas-
s e n g e r s w e r e injured.
Investigation and Evidence
On the day of the accident the pilot had
completed two r e t u r n flights between J e r s e y
and Blackbushe a r r i v i n g back i n J e r s e y a t 1808
h o u r s Greenwich Mean Time. After a n i n t e r -
val of about 3 3 minutes, during which t i m e he
completed a r r i v a l and d e p a r t u r e f o r m a l i t i e s ,
he took off f o r Blackbushe. Shortly before 1925
h o u r s when a t 2 300 feet and about t h r e e m i l e s
south of St. C a t h e r i n e ' s Point, Isle of Wight,
the pilot r e p o r t e d t o London Air T r a f f i c Control
that the s t a r b o a r d engine was running v e r y
roughly and, a minute l a t e r that the p r o p e l l e r
constant-speed unit had failed and the engine
was losing power. An attempt w a s made to
c l e a r the surging by operating the s t a r b o a r d
throttle and pitch l e v e r s through t h e i r full
range but without effect. The pilot stated thdt
a s height was being l o s t he opened up the p o r t
engine to climbing power and then t o fullpower
but that descent continued. No feathering ac-
tion w a s taken. He had no recollection of
checking the fuel p r e s s u r e warning lights o r
the contents of the p o r t tanks but said that he
checked the contents of the s t a r b o a r d m a i n
tank and that the gauge indicated 15 20 gal- - w e r e within the m a k e r ' s p r e s c r i b e d l i m i t s ,
lons.
At 1930 h o u r s the pilot reported h i s
position a s over the Isle of Wight at 1 000 feet,
a t 1932 h o u r s a s approaching Southampton
Water at 800 f e e t and a t 1935 h o u r s a s f o u r
m i l e s e a s t of Calshot. Almost immediately
a f t e r w a r d s the p o r t engine a l s o l o s t power and
a MAYDAY call w a s t r a n s m i t t e d ; this w a s
acknowledged by Eastleigh. The a i r c r a f t was
successfully ditched a t 1936 h o u r s . T h e r e was
no f i r e .
No warning of the e m e r g e n c y had been
given t o the p a s s e n g e r s but they had t h e m s e l v e s
concluded that a l l w a s not well. One m a n who
did not know how to f a s t e n h i s safety belt
c o r r e c t l y sustained f r a c t u r e d r i b s and the pas-
s e n g e r i n the cockpit r e c e i v e d a c u t o n the f a c e .
When the a i r c r a f t c a m e to r e s t i t
r e m a i n e d afloat and m o s t of the occupants got
o u t onto the p o r t wing and top of the fuselage
where life jackets w e r e put on. One p a s s e n g e r ,
who had been sitting in the cockpit, did not know
w h e r e h i s life jacket w a s stowed and another
p a s s e n g e r had been unable to find h i s , s o the
pilot re-entered the a i r c r a f t and found life
j a c k e t s for both of them.
Inspection of the a i r c r a f t revealed t h a t
it was only slightly damaged during the ditching.
T h e r e was no evidence of any p r e - c r a s h damage
o r mechanical failure. The fuel tanks w e r e
empty except f o r the s t a r b o a r d inner which
contained about five gallons of a mixture of
p e t r o l and s e a water. The fuel tank cocks w e r e
s e l e c t e d "ON" and the c r o s s f e e d cock was i n the
"OFF" position. The fuel f i l t e r s w e r e clean
and f r e e f r o m w a t e r ; e a c h contained a s m a l l
quantity of fuel. The fuel s y s t e m w a s p r e s s u r e -
t e s t e d and no l e a k s w e r e found. The fuel deliv-
e r y and vent l i n e s w e r e f r e e and unobstructed.
It was not possible to check the fuel p r e s s u r e
warning lights o r the fuel tank contents gauge
owing t o the effects of i m m e r s i o n in the s e a .
The c a r b u r e t t o r s , complete with the
boost and m i x t u r e control units, w e r e removed
and tested a t the m a k e r s . The t e s t s showed
t h a t they w e r e s e r v i c e a b l e and that the fuel flows
Although the pilot s t a t e d that before
taking off he twice r e a d the fdel contents gauge
and was satisfied f r o m the readings that the
a i r c r a f t had been refuelled, investigation a t
J e r s e y A i r p o r t revealed that the a i r c r a f t had
not been refuelled, that the tanks had not been
inc,pectcd for the amount of fuel they contained
cind that the a i r c r a f t left J e r s e y with only such
p e t r o l ds renidined in the tanks dfter the fllght
f r o m Bl'ickbushe.
 ICAO C i r c u l a r 50-AN/45
Observations
It i s considered that the a r r a n g e m e n t s
m a d e by the o p e r a t o r f o r the refuelling of their
a i r c r a f t a t J e r s e y w e r e not sufficiently defi-
nite and that t h i s led to a breakdown in the
procedure.
In addition, the pilot r e l i e d on h i s
reading of the fuel contents gauge a s a m e a n s
of satisfying himself that the a i r c r a f t had been
refuelled and this c l e a r l y gave r i s e to e r r o r .
When the s t a r b o a r d engine l o s t power
the pilot did not c a r r y out a thorough cockpit
check to e s t a b l i s h t h e c a u s e of the f a i l u r e and
ICAO Ref: AR/429
171
e r r o n e o u s l y concluded that because the engine
w a s surging the p r o p e l l e r constant-speed unit
w a s defective. Had he established that the fuel
w a s a l m o s t exhausted h e might well have been
able to land on a n a e r o d r o m e i n the I s l e of Wight.
The Company's o p e r a t i o n s manual
m a k e s i t c l e a r that in o r d e r to maintain height
o n one engine the p r o p e l l e r of the failed engine
m u s t be feathered.
P r o b a b l e Cause
The accident w a s due t o lack of fuel
resulting in l o s s of power f r o m both engines
and a f o r c e d alighting i n the s e a .
 172 ICAO Circular 5 0 - A ~ / 4 5

No. 39

DC-3, PP-CBY, crashed a t S e r r a do Caparao, State of Espi'rito Santo

on 26 August 1955. Brazilian Commercial Accident Report No. 3-C-55
published 1 November 1955. -
Circumstances The appearance of the m a r k s made by the
a i r c r a f t in crashing shows that i t was flying a t
The a i r c r a f t took off f r o m Rio for Cara- an altitude of 1 500 m e t r e s and heading for
velas with an IFR flight plan specifying flight a t Caravelas. It may, therefore, be assumed
1 500 m e t r e s along airway Vd-1, carrying 4 that the pilot-in-command, instead of following
crew m e m b e r s and 9 passengers. After 58 airway Vd-1 along the coast, decided to cut
minutes of flight the a i r c r a f t reported that i t directly a c r o s s f r o m Rio to Caravelas. He re-
was over Campos a t 1 500 m e t r e s . There was ported flying over Campos when in fact he was
no further news f r o m the a i r c r a f t whose wreck- only a b r e a s t of this location. Finally, pursuing
age was later discovered on the summit of the flight on instruments, he crashed unexpect-
F o r n o Grande in the State of Espirito Santo. edly into the uncharted peak.
There were no survivors and the a i r c r a f t was
destroyed.
Probable Cause
Investigation and Evidence

The weather conditions between Rio and

Campos were good. There was an alto-stratus
layer a t 2 000 m e t r e s and 4 to 618 of cumulus
and strato-cumulus between 400 and 600 m e t r e s .
The Forno Grande peak i s more than
1 500 m e t r e s high but is not marked on current
navigation charts which represent the whole of
that a r e a a s having an elevation lower than
1 200 m e t r e s . It i s situated a little to the right
(10 km) of the direct Rio-Caravelas route and,
according to reports obtained locally, was cov-
e r e d by cloud at the approximate time (0800
hours) of the accident.
The accident was due to the Forno Grande
peak not being indicated on c u r r e n t charts, the
flight being conducted outside the airway and
failure to adhere to the approved flight plan.
Recommendation
It i s recommended that the following be
shown on navigation charts:
200 2 5 5 - 41° 06tW, spot elevation
above 1 500 m.

I C A O Ref: A I G / A C C / K E P / G E N / N O . 8
( N o . 3 - C - 55)
 ICAO Circular 5 0 - ~ ~ / 4 5
No. 40
Continental Air Lines Inc.. DC-3, and Hines Flying Service, P i p e r PA-22.
collided on f ~ n a approach
l a t the L e a ~ o u n i i ; ~ o r tHobbs,
on 29 August 1955. Civil Aeronautics Board (U.S.A.) Accident Investigation
R e ~ o r SA-310.
t File No. 1-01 11 released on 11 Januarv 1956.
Circumstances
The Continental Air Lines' Flight origi-
nated a t El Paso, Texas for Houston, Texas and
the stops were scheduled a t Carlsbad and Hobbs,
New Mexico and a t Midland-Odessa, San Angelo,
and Austin, Texas. The DC-3 left El P a s o a t
1120 hours Mountain Standard Time and a r r i v e d
a t Carlsbad on schedule a t 1215 hours. Depar-
t u r e for Hobbs was a t 1217 hours on a VFR
flight plan with 11 passengers and a c r e w of 3
on board. At 1237 the flight asked L e a County
Airport if there was any local traffic and was
advised that none was visible f r o m the terminal.
When approximately 3-1/2 m i l e s f r o m the a i r -
port the f i r s t officer turned right to a heading
of 120 degrees starting a base leg for Runway 3
and maintained a n altitude of 4 500 feet m. S. 1. ,
about 840 feet above the ground, while on the
base leg. A left turn f r o m b a s e to final for Run-
way 3 was made approximately 2-1/2 miles out
and about 800 feet above the ground. At one-
half mile out flaps were extended fully a t an a i r -
speed of 95 knots. The captain called the a i r -
speed with each 5 knots change and the a i r c r a f t
crossed the field boundary a t 80 knots. At this
time the captain saw f r o m the left side window
the shadow of an a i r c r a f t converging with his
flight path over the runway. He skidded the a i r -
c r a f t evasively to the right, used emergency
power and called for gear up. He then saw a
P i p e r T r i - P a c e r close ahead, above and nearly
into his left propeller. Almost instantly the
propeller struck the tail surfaces of the P i p e r .
The DC-3 made a n emergency pullout, circled
the a i r p o r t and landed on Runway 17 without
further incident. None of the 14 occupants were
injured.
The Piper PA-22 departed Wichita Falls,
Texas, at approximately 0950 hours on a VFR
flight for Hobbs, New Mexico, carrying one oc-
cupant, the pilot. He proceeded on a south-
westerly course a t a n altitude of 5 000 feet
m. s. 1. At 1239 the pilot called Hobbs request-
ing surface wind direction and velocity and al-
timeter setting. Hobbs replied, adding that the
wind favoured Runway 3 and that caution should
be exercised because of men and equipment in
the field. At this point the a i r c r a f t was approx-
imately five miles northeast of the a i r p o r t and
173
, N ~ W
MexicF
a t a n altitude of 4 700 feet m. s . 1. On nearing
the a i r p o r t the pilot a l t e r e d h i s course slightly
to the left i n o r d e r to enter the traffic pattern
on a downwind leg for Runway 3. This leg was
flown a t a n altitude of approximately 4 460 feet
m. s. l . , 800 feet above the ground, about one-
half to three-quarters of a mile to the west-
northwest of Runway 3. The pilot stated that
while flying the downwind leg, he looked for
other traffic and saw none. He said he made a
left turn, establishing a base leg about 1/4mile
long, and again checked the a r e a for other traf-
fic. None was seen.
The left turn to final was steepened and a t
an airspeed of approximately 68 knots, full flaps,
to the second notch, were applied, As he neared
the approach end of Runway 3, he realized that
he was too high and s t a r t e d a forward slip to
lose altitude and land short on the runway. At
this time his airspeed was between 45 and 55
knots. J u s t after passing the end of the runway,
he heard a loud r o a r and on glancing out of the
right window he saw the nose of another a i r c r a f t
alongside and slightly above him. At this point
the two a i r c r a f t collided and the P i p e r crashed
to Runway 3 some 560 feet f r o m its approach
end. The time of collision was approximately
1245 and the altitude was 30-40 feet.
Investigation and Evidence
The offlcial weather a t the a i r p o r t a few
minutes after the accident was reported as:
Ceiling estimated 7 000 broken, broken clouds
a t 25 000; visibility 15 plus; wind east-northeast
5; altimeter 29.95. The sun was plainly visible
a t a computed elevation above the horizon of 64
degrees; its bearing was slightly west of south.
The a i r was moderately turbulent. The pilots
of both a i r c r a f t testified that their respective
windshields were clean.
Impact was between the left propeller of
the DC-3 and the empennage of the P l p e r . It
was possible to reconstruct partially the shat-
tered empennage of the Piper by matching p a r t s
and pieces of ripped fabric against a s i m i l a r
aircraft. This studv showed that the f i r s t pro-
peller blade contact cut off the navigation light
on the trailing edge of the rudder. Subsequent
 174 ICAO Circular 5 0 - ~ ~ / 4 5
propeller cuts sliced through the rudder and ele-
vators, continued forward through the fin and
stabilizers, and finally tore a p a r t the aft fuse-
lage almost a s far forward a s the baggage com-
partment. The cuts in the rudder and left ele-
vator were quite distinct, nearly parallel, and
sufficiently uniform in spacing to allow a com-
putation of the difference in speeds of the two
aircraft. The engines of the DC-3 were a t a
probable speed of about 2 700 r . p . m . , and the
difference in the horizontal components of the
two speeds was approximately 13 knots, the
DC-3 travelling faster.
The angles of the propeller cuts relative
to the longitudinal axis of the Piper tell the
relative attitude of the two a i r c r a f t a t the time
of and for a very brief period immediately fol-
lowing f i r s t impact. The longitudinal axis of
the P i p e r diverged about 7 degrees to the left
and about 7 degrees downward f r o m the longitu-
dinal axis of the DC-3. The Piper was banked
to ~ t left
s (the DC-3 was level laterally) by an
amount not readily determinable f r o m the cuts
but the P i p e r pilot estimates the bank a t 30
degrees and the DC-3 captain estimates i t a t 15
degrees. At the moment of f i r s t contact the left
propeller hub of the DC-3 was about three feet
f r o m the bottom of the rudder and about one-half
foot left of the centreline of the Piper.
Damage to the DC-3 was caused by small
metallic pieces f r o m the empennage of the Piper
being thrown by the left propeller of the DC-3.
Some of these pieces penetrated the fuselage and
ripped clothing that was hanging just behind the
pilots, but control of the a i r c r a f t was not af-
fected. The left propeller bore deep m a r k s of
impact.
Continental Air lines1 Operations Manual
prescribes that a t all uncontrolled airports ap-
proaching flights shall establish a base leg prior
to starting final in o r d e r to observe other traf-
fic more adequately. The DC-3 pilots testified
that they conformed to this requirement a s they
approached the airport and flew to the left in
o r d e r to establish a base leg. Their testimony
was confirmed by ground witnesses.
The Piper approached the airport f r o m a
direction substantially opposlte that of Runway 3
and to the northwest of that runway. It was then
flown on the downwind leg in a direction approx-
lmately opposite Runway 3 to a point about
abreast of its approach end. Consequently ap-
proximately 180 degrees of left turn was neces-
s a r y to align with that runway. Testimony of com-
petent ground witnesses indicates that this turn
was continuous o r nearly so, with the a i r c r a f t
banked appreciably throughout the turn. It also
indicates that the P i p e r was the higher of the
two a i r c r a f t a s both approached the runway, the
DC-3 in straight descending flight and level lat-
erally, the P i p e r in a rather sharp left turn
merging into a left forward slip just before col-
lision. These flight paths were confirmed short-
ly after the accident by ground observations of
simulated approaches of two identical aircraft.
(Refer to Figure 23).
At 1237 the DC-3 reported to i t s own com-
pany radio station at the airport. At 1239 the
P i p e r reported to the Hobbs CAA radio. The CAA
radioman and the GAL operator. in separated
offices in the same building, did not exchange
their respective items of traffic ~nformation.
Airport authorities had published local
traffic rules accompanied by the conventional
left-hand traffic diagram several y e a r s e a r l i e r .
These rules and diagram had m e t with CAA ac-
ceptance inasmuch a s they had originally been
submitted to the CAA and had been posted con-
spituously a t the airport. The P i p e r pilot testi-
fied that he was familiar with these trafflc rules.
The DC-3 captain's l a s t route check was on 21
March 1955 and included Lea County Airport.
It complied with company approach procedures,
which a r e in accord with local traffic rules.
The Lea County Airport i s on flat t e r r a i n
offering no significant obstruction to vision in
any direction. The two a i r c r a f t involved were
the only two in the a i r a t the time and place of
the accident.
Regardless of the numerous devlces and
m e a s u r e s such a s traffic rules and diagrams that
have beendevised to lessen collision hazard, noth-
ing a s yet has replaced fully the cardinal princi-
ple of seeing and being seen. This responsibility
r e s t s in cockpits. At uncontrolled airports,
such a s Lea County, the principle of "see and
be seen" becomes of paramount importance.
Experience has well demonstrated that the ap-
proach end of a runway at uncontrolled alrpirts
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 175

i s the focal point of danger. T h e r e a r e two can s e e other a l r c r a f t sufficiently to provide

Clvil A l r Regulations that a r e pertinent to thls adequate traffic separation, pilots m u s t a s s u m e
collision. * complete responsibility a g a i n s t collision.

It i s o b v ~ o u sthat full utilization of the It i s obvious that had e i t h e r the pilots of

principle of s e e and b e s e e n couldhave prevent-
ed this accident. I t i s a l s o plain that neither
pilot did s e e the other's a i r c r a f t untll only a
very brief time before c o l l ~ s i o n . The DC-3 was
flown in such a manner that the P i p e r should
have been wlthln vision f r o m the DC-3 cockplt
f o r a substantial t i m e i n t e r v a l untll very short-
ly before the collision. The P i p e r was flown In
such a m a n n e r that the DC-3 should have been
visible f r o m i t s cockpit except f o r a s h o r t pe-
riod just before the c r a s h ( a s i t made a continu-
ous t u r n f r o m downwind to final). The P i p e r i s
a high-wing a i r c r a f t and although the right wing
itself would not block vision during a left turn,
i t s fuselage s t r u c t u r e could have been ~ n t e r -
posed in the line of sight toward the DC-3 to the
right, and a s the P i p e r was the higher of the
two a i r c r a f t during the final p a r t of the approach-
e s , this difference in altitude m u s t have become
increasingly significant - in r e f e r e n c e to taklng
each a i r c r a f t out of the o t h e r ' s n o r m a l field of
vision - a s the pdths of the a i r c r a f t intersected.
Also, under the conditions of being in a f o r w a r d
s l i p to lose altitude and thus land s h o r t , the
P i p e r pilot m u s t certainly have been looking
ahead and down f r o m the left side.
The concept of s e e and be s e e n r e q u i r e s
that under c o n d ~ t i o n sof visibility in which pilots
the DC-3 o r the pllot of the P i p e r e x e r c i s e d the
continuous vigilance r e q u i r e d by VFR flight d u r -
ing landing approach the other a i r c r a f t would
have been s e e n in t i m e to avoid collision.
The B o a r d concluded t h e r e f o r e , that nei-
t h e r pilot was sufficiently vigilant and a l s o that
the P i p e r was not flown in full accordance with
the a i r p o r t traffic pattern.
I t i s probably t r u e that the e x t r e m e l y
s m a l l amount of a l r traffic a t Hobbs A i r p o r t and
the fact that n e i t h e r a i r c r a f t was advised of the
o t h e r ' s p r e s e n c e may have l e s s e n e d the pilot's
alertness.
A s a r e s u l t of this accident a n intercommu-
nication s y s t e m h a s been installed between Con-
tinental's radio r o o m and the CAA's radio office
s o that all traffic information can be quickly
available to both.
P r o b a b l e Cause
The probable cause of this accident was
lack of sufficient visual a l e r t n e s s on the p a r t of
the pilots of both a i r c r a f t , and f a i l u r e of the
P l p e r pilot to comply fully with the local traffic
pattern.

* 1t60.12 C a r e l e s s o r r e c k l e s s operation. No p e r s o n s h a l l o p e r a t e a n a i r c r a f t in a c a r e l e s s o r
r e c k l e s s manner s o a s to endanger the life o r property of o t h e r s .

c) L a c k of vigilance by the pilot to o b s e r v e and avoid other a i r traffic. In this r e s p e c t , the pi-
lot m u s t c l e a r h i s position p r i o r to s t a r t i n g any manoeuvre, either on the ground o r in flight."

"60.14 Right-of-way.

d ) Overtaking. An a i r c r a f t that i s being overtaken h a s the right-of-way, and the overtaking a i r -

c r a f t , whether climbing, descending, o r in horizontal f l ~ g h tshall keep out of the way of the o t h e r
a i r c r a f t by altering i t s c o u r s e to the rlght, and no subsequent change in the relative position of the
two a i r c r a f t shall absolve the overtaking a i r c r a f t f r o m this obligation until i t i s entirely p a s t and
clear;

)'NOTE: P a s s i n g a n overtaken a i r c r a f t on the right 1s r e q u i r e d b e c a u s e the pilot in side-by-side,

dual-control a l r c r a f t i s s e a t e d on the left and h a s a b e t t e r view on that side. F u r t h e r , in n a r r o w
traffic lanes, passing on the left of a n overtaken a l r c r a f t would place the overtaking a i r c r a f t in the
path of the oncoming traffic.

I4e) Landing. A i r c r a f t , while on the final approach to land, o r while landing, have the right-of-
way over other a i r c r a f t in flight o r operating on the s u r f a c e . When two o r m o r e a i r c r a f t a r e a p
proaching an a i r p o r t for the purpose of landing, the a i r c r a f t a t the lower altitude h a s the right-of-
way, but i t shall not take advantage of this r u l e to cut ln front of another which i s on final approach
to land, o r to overtake that a i r c r a f t .

"NOTE: Pllots lnust recognize that once committed to a landlng in c e r t a i n a i r c r a f t the pilot h a s
little chance to avoid other a i r c r a f t which may i n t e r f e r e with that landing and, t h e r e f o r e , careful
observance of thls rule is important to the safety of all concerned."
 ICAO Circular 50-AN/ 45

1 LMTLR TRAIFlC
Points @ and @ @ ore computed I
positions o the two aircraft at 30 seconds
and 60 seconds, respectively, betom collision,
and ore based on assumed average speeds of
60 knots and 90 knots for the Plper and
the DC- 3 respeclive ly.

' ~PROlABUALTlT UDE Of DC-8 )

Figure 23

LEA COUNTY AIRPORT

AIRPORT ALTlTUDr 8089' Y.1L. HOBeS N M.

4 U L I
AIR COLLISION BETWEEN
CONTINENTAL A I R LINES OC-3 N16945
and
HlNES FLYING SERVICE PIPER N53348
AUGUST 29, 1955
Oo~Do-64602
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
No. 41
C u r r e y A l r T r a n s p o r t , L t d . , DC-3C, s t r u c k powerlines during a t t e m p t e d
e m e r g"e n c v landlne" and c r a s h e d a t Lockheed A i r T e r m i n a l . Burbank. California . - - -
on 8 S e p t e m b e r 1955. Clvil A e r o n a u t i c s B o a r d (USA) Accident Investigation
R e p o r t No. SA-312, F i l e No. 1-0109 r e l e a s e d 1 3 F e b r u a r y 1956.
Circumstances
The flight (non-scheduled) took off a t
0751 h o u r s P a c l f i c S t a n d a r d T l m e f r o m Lock-
heed A i r T e r m i n a l , Burbank, California f o r
Oakland, California, c a r r y i n g 30 p a s s e n g e r s
and a c r e w of t h r e e . A Defence Visual F l i g h t
Rules fllght plan had been flled. The take-off
a t 0751 h o u r s f r o m Runway 15 w a s completed
and the a i r c r a f t climbed in a n o r m a l m a n n e r
into s m o k e h a z e which was m o r e d e n s e t o w a r d s
the south and i n whlch i t w a s l o s t to o b s e r v e r s
a t the a i r p o r t . At 0752 the a i r c r a f t called the
tower requesting a n e m e r g e n c y landing c l e a r -
a n c e whlch was immedlately granted. A t ap-
proximately 0756 the control tower o p e r a t o r
sighted the fllght about one m i l e t o the south-
west, proceeding i n a nose-high attitude toward
the a i r p o r t but not aligned wlth any runway.
A c r o s s the a p p r o a c h t r a c k belng used w a s a
powerline about 500 f e e t s h o r t of the a i r p o r t
boundary. A s t h i s line w a s approached the
nose-hlgh attitude i n c r e a s e d and immedlately
a f t e r p a s s i n g t h ~ spowerline the a i r c r a f t exe-
cuted a slight left t u r n , banked 10 t o 1 2 d e g r e e s .
T h e left wing then s t r u c k a s e r v i c e powerline a t
the a i r p o r t boundary. The a l r c r a f t s t a l l e d , i t s
left wing collided with two p a r k e d C-54's, i t
cartwheeled, s l i d a c r o s s the a p r o n and s t r u c k
a Lockheed S e r v i c e H a n g a r , comlng to r e s t i n
the open doorway of that h a n g a r . The fuselage
b r o k e open a t a point behlnd the wing and m o s t
of the s u r v i v o r s e s c a p e d o r w e r e r e s c u e d
through this opening. The captain and co-pilot
w e r e killed, the s t e w a r d e s s and one p a s s e n g e r
w e r e s e r i o u s l y i n j u r e d and the r e m a i n i n g 29
p a s s e n g e r s r e c e i v e d m i n o r l n j u r l e s . One p e r -
s o n on the ground was fatally injured and the
a i r c r a f t w a s a l m o s t totally d e s t r o y e d by i m -
pact.
Investlgatlon and Evldence
All m a j o r a s s e m b l i e s of the a i r f r a m e
w e r e extensively d a m a g e d due t o i m p a c t with
the two o t h e r a i r c r a f t , the ground and the han-
g a r . The landlng g e a r was found down and lock-
ed and the flaps w e r e r e t r a c t e d .
177
All e l e c t r i c a l l y o p e r a t e d powerplant shut-
off valves t o the two engines w e r e e x a m i n e d
carefully. They w e r e positioned a s follows:
Rlght powerplant, o i l and h y d r a u l i c , both fully
closed; left powerplant, oil one-half c l o s e d , hy-
d r a u l i c two-thirds closed. F u e l c r o s s f e e d
v a l v e s w e r e c l o s e d , t h e r i g h t engine fuel valve
w a s i n the left m a i n tank position, and t h e left
engine fuel valve w a s In t h e r i g h t m a i n tank
position.
Complete teardown examination of both
engines d i s c l o s e d that: The left engine, e x c e p t
f o r i m p a c t d a m a g e , w a s capable of delivering
i t s power in a n o r m a l m a n n e r . T h e r i g h t engine
had sustained i n t e r n a l d a m a g e during o p e r a t i o n ;
a s m a l l amount of b e a r i n g m e t a l w a s p r e s e n t i n
the m a i n oil s u m p . The f r o n t m a s t e r r o d b e a r -
ing had o v e r h e a t e d but t h e r e w a s no a p p r e c i a b l e
l o s s of i t s b e a r i n g m e t a l ; i t had l o s t about 50
p e r c e n t of i t s lead-indium coating but none of
i t s s i l v e r p l a t i n g . The r e a r m a s t e r rod had b e e n
discolored by heat; the lead-indium coating of
i t s b e a r i n g h a d b e e n w o r n away and about 4 0 p e r -
cent of the s i l v e r p l a t i n g had b e e n w o r n f r o m the
s h e l l of i t s upper half. The s i l v e r p l a t i n g of the
l o w e r half of this b e a r i n g w a s badly s c o r e d .
The r i g h t p r o p e l l e r g o v e r n o r and a l l the o i l p a s -
sages serving it were free f r o m foreign mate-
r i a l and w e r e capable of n o r m a l o p e r a t i o n .
The b l a d e s of the left p r o p e l l e r w e r e a t
32 d e g r e e s when i m p a c t o c c u r r e d ; those of the
r i g h t p r o p e l l e r w e r e a t 18 d e g r e e s ,
Examination of the f e a t h e r i n g c i r c u i t s of
the right propeller disclosed an intermittent
open c i r c u i t i n the w i r e connecting the f e a t h e r i n g
button holding c o l l and the f e a t h e r i n g pump r e -
lay. The c a u s e of the open c i r c u i t w a s a loose
s o l d e r e d connection o n the holding c o i l t e r m i n a l .
T h i s condition could have b e e n produced by i m -
p a c t f o r c e s that s e v e r e l y d a m a g e d the o v e r h e a d
p a n e l upon which the f e a t h e r i n g switch w a s
mounted.
Examinatloll of the w r e c k a g e d i s c l o s e d no
m a r k s of f l r e t h a t could have o c c u r r e d p r t o r to i m p a c t
178 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
Questlonlng of a l l w i t n e s s e s , includlng a v a i l a -
ble p a s s e n g e r s , d i s c l o s e d that none of t h e m had
s e e n any s m o k e , s p a r k s , o r o t h e r indication of
r e a l o r lmpendlng f i r e durlng flight.
The r i g h t engine had b e e n overhauled o n
9 F e b r u a r y 1955, 140:54 h o u r s b e f o r e the acci-
dent. A t that t i m e both m a s t e r r o d s w e r e fitted
with b e a r i n g s r e p r o c e s s e d by the engine manu-
f a c t u r e r . R e c o r d s of t h i s o v e r h a u l and of the
t e s t s which followed showed t h a t a l l p a r t s w e r e
w i t h ~ nm a n u f a c t u r e r ' s l i m i t s and t h a t engine p e r -
formance was normal.
Examination of a l l maintenance r e c o r d s of
the a l r c r a f t shows t h a t the l a s t No. 1 check was
m a d e t h r e e d a y s before the accident when the
logged t i m e w a s 9,849:23 h o u r s , 2: 16 h o u r s
s h o r t of the t i m e when t h i s inspection w a s due.
Work s h e e t s of the l a s t No. 2 inspection,
dated 23 August 1955, and No. 3 inspection.
dated 20 July 1955, d i s c l o s e d t h a t a l l i t e m s
w r i t t e n up w e r e r e p a i r e d , inspected, and signed
off.
Review of the flight logs back through 2 0
August 1955, d i s c l o s e d no r e c o r d of any o p e r a -
ting difficulty with e i t h e r powerplant.
Testimony of e y e w i t n e s s e s m a d e i t pos-
s i b l e to plot the path of the a i r c r a f t b a c k about
3-1/2 m i l e s f r o m the point of impact. F i g u r e
24 shows this portion of the flight path in r e l a -
tion to the runways and t o the take-off path.
The position of the a l r c r a f t a t the t i m e the c r e w
b e c a m e a w a r e of the e m e r g e n c y and immediate-
ly t h e r e a f t e r i s not definitely known and that
portion of the flight path i s not shown.
Weather a t the t i m e of t h e incident: 0758.
-
Special observation P a r t i a l obscurement, ten
thousand, b r o k e n clouds, visibility one and
s e v e n eighths m i l e s , h a z e and s m o k e , s m o k e
l a y e r ten thousand.
A pilot who had just landed r e p o r t e d t h a t
the visibility t o the south was w o r s e b e c a u s e of
s m o k e than it w a s a t the a i r p o r t o r t o the north.
This w i t n e s s s t a t e d t h a t if the flight had a s
much a s 3 500 f e e t o r 4 000 f e e t f o r w a r d visibil-
ity f r o m the 300-foot l e v e l i t would be very f o r -
tunate.
S e v e r a l of the ground w i t n e s s e s described
the engine sound and visible rotatlon of the p r o -
p e l l e r s a s n o r m a l f o r the l e f t but s l o w e r and
i r r e g u l a r f o r t h e right. One competent w ~ t n e s s
s t a t e d that the right prop s e e m e d to b e I1golng
in and out of feather".
All quallfled o b s e r v e r s of the e m e r g e n c y
a p p r o a c h gave d e s c r l p t l o n s of the attitude o f t h e
a i r c r a f t a s nose-hlgh and i t s s p e e d a s slow.
The chlef pilot of C u r r e y w a s questioned
r e g a r d i n g the training of C u r r e y pilots. With
p a r t i c u l a r r e g a r d t o the single-engine p r o c e d u r e s
t r a i n i n g of the captain of this flight he testified:
" T h e s e s a m e p r o c e d u r e s w e r e given t o t h e captain
in h l s t r a i n l n g p r o g r a m . In f a c t , I might a d m i t
to the r e c o r d that h e had t o p e r f o r m , to the b e s t
of m y knowledge, t h r e e o r four of these manoeu-
vres.
Company t r a i n i n g p r o c e d u r e a t Lockheed
A i r T e r m i n a l f o r s~ngle-engine r e t u r n on i n s t r u -
m e n t s s t a r t s with pilot a l r e a d y under a hood and
on i n s t r u m e n t s . The p r o c e d u r e s t a r t s with a
c l i m b t o 2 000 f e e t o n a c o u r s e of 255 d e g r e e s
( p a r a l l e l t o the ILS leg a t Lockheed A i r T e r n i i -
n a l which i s 255 d e g r e e s outbound). At 2 000
f e e t and beyond the m a r k e r he e x e c u t e s a t u r n
toward the leg and t h e m a r k e r , i n t e r c e p t s the
glide path and l o c a l i z e r , and c o m p l e t e s h i s 2p-
proach. Company method of p r a c t i s i n g single-
engine r e t u r n a f t e r take-off is t o u s e a lightly
loaded a i r c r a f t ; i t p r e s c r i b e s throttling the en-
gine to little o r no t h r u s t In lieu of feathering.
The captain and the co-pilot h a d both b e e n check-
ed out on t h ~ sp r o c e d u r e .
The chief pilot a l s o testified that he had
used the subject a i r c r a f t f o r a 40-mlnute pllot
qualification flight (of another pilot) ending about
30 minutes p r i o r to the take-off of the flight.
T h i s training fllght utilized a preflight check
which Included the functional testing of the feath-
e r i n g of both p r o p e l l e r s . his check i s r e q u l r e d
by the c a r r i e r p r i o r to e v e r y flight.) No m a l -
function w a s noted i n engine o r p r o p e l l e r p e r -
formance.
All a i r b o r n e radio, navigation, and c o m -
munications equipment w a s u s e d without m a l -
function during this flight which included a single-
engine i n s t r u m e n t approach. During the investi-
gation a l l a i r b o r n e r a d i o units w e r e examined
and no evidence w a s found t o indicate that i t had
not been in operating condition p r l o r to i m p a c t .
Immediately a f t e r the accident a l l ground r a d i o
f a c l l ~ t l e sincludlng the ILS f o r runway 7 w e r e
tested; a l l functioned n o r m a l l y .
Since the c r e w neither s u r v i v e d nor de-
s c r i b e d the e m e r g e n c y by r a d i o ~t 1s possible to
recor.struct what transpired on the flight deck
only b y c o n s ~ d e r a t l o nof the factual m a t e r ~ a lal-
ready preseilted,
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
Take-off was under visual flight r u l e s and
was m a d e toward the south-southeast into h a z e
which r e s t r i c t e d horizontal visibility and b o r d e r -
ed on conditions r e q u i r i n g i n s t r u m e n t flight.
T h e r e i s nothing t o indicate that flight by vis-
ual r e f e r e n c e s had b e e n discontinued when the
e m e r g e n c y was c a u s e d by the difficulty with the
r i g h t engine one t o two m i n u t e s l a t e r .
The malfunction which o c c u r r e d in the
r i g h t powerplant would have been evidenced by
r i s i n g oil t e m p e r a t u r e , dropping 011 p r e s s u r e ,
and r o u g h n e s s , a l l d i s c e r n i b l e to the pilot.
T h i s malfunction did not of itself c a u s e very
g r e a t l o s s of power and t h e r e i s no r e a s o n t o
believe that it included a f i r e warning. Con-
tlnued u s e of power on the r i g h t engine f o r a
b r ~ e fp e r i o d would have been h a z a r d o u s but p o s -
s i b l e . P o w e r reduction a t t h a t instant w a s p r e -
cautionary.* The p r o p e l l e r of this engine con-
tinued to r o t a t e until i m p a c t ; i t s pitch was then
18 d e g r e e s indicating that little o r no power was
being developed.
This w a s the captain's f i r s t take-off with
this co-pilot. Upon noting the malfunction of h i s
r i g h t engine the captain a s k e d the tower f o r and
received emergeniy c l e a r a n c e to r e t u r n and u s e
Runway 7. Runway 7 i s the ILS runway and i t s
glide path and locaLizer w e r e available t o guide
the flight in establishing alignment and ccm-
pleting i t s landing.
The a i r c r a f t w a s loaded c l o s e to b u t with-
in legal l i m i t s and the p e r f o r m a n c e of this model
s o loaded i s known t o b e s u c h that a s a f e m a r g i n
e x i s t s which would have p e r m i t t e d i t to climb on
one engine a t take-off power. Under the w o r s t
possible combination of p r o p e l l e r and landing
g e a r positions i t would have b e e n just a b l e t o
m a i n t a i n level flight a t METO* power i f the a i r -
speed w a s maintained a t V2 ( 9 7 m p h ) o r m o r e .
Climb would have b e e n p o s s i b l e if the g e a r had
b e e n r e t r a c t e d , t h e p r o p e l l e r had b e e n f e a t h e r -
ed, o r any t h r u s t a t a l l had b e e n developed b y
the malfunctioning engine.
T h e s e known p e r f o r m a n c e d a t a indicate
t h a t the a i r c r a f t w a s not incapable of making a
s a f e r e t u r n a f t e r u s e of i t s right engine had b e e n
discontinued.
The o b s e r v e d portion of the flight path,
c h a r t e d in F i g u r e 2 4 d o e s not include the b a s e
leg of the approach.
* Cockpit c h e c k l i s t specified " F e a t h e r " f o r single -engine operatlon; power setting 2 5 5 0 r p m
and 4 2 ~ n c h e s f; o r M E T 0 power 2. 550 r p m and 41 inches.
179
When the malfunction o c c u r r e d the captain
m a y have c o n s i d e r e d h i s altitude insufficient f o r
s a f e t r a n s i t i o n f r o m visual to i n s t r u m e n t flight,
o r f o r r e l i a n c e on h i s co-pilot f o r much, if ally,
h e l p on this t h e i r f i r s t flight together. H e m a y
have t r i e d t o continue flight by visual r e f e r e n c e
only, o r he m a y have been guided by the ILS in-
n e r m a r k e r a t the a p p r o a c h end of Runway 7.
The flight path a f t e r the e m e r g e n c y w a s announced
indicated single-engine o p e r a t i o n and s i n c e the
malfunction did not cut out the engine the captaln
m a y have r e d u c e d power o n t h a t engine a s done
i n C u r r e y l s p r a c t i c e of single-engine flight; o r
he m a y have t r l e d unsuccessfully to f e a t h e r the
r i g h t p r o p e l l e r . The fully c l o s e d position of the
r i g h t engine shutoff valves i n d i c a t e s t h a t f e a t h e r -
ing w a s attempted. The shutoff valves of the l e f t
engine w e r e in a midposition indicating t h a t the
c r a s h m a y have i n t e r r u p t e d t h e i r closing.
The captain did not, and possibly could not,
c l i m b t o 2 000 f e e t and follow t h a t p o r t i o n of thc
company's single-engine t r a i n i n g p r o c e d u r e . I3e
did c i r c l e to t h e r i g h t f o r a n a p p r o a c h to Runway
7. If he used h i s r a d i o and the l o c a l i z e r he need-
ed a b a s e leg s o m e d i s t a n c e o u t to enable h i m t o
a l i g n the runway by t h a t m e a n s . If h e depended
on visible l a n d m a r k s h e needed a b a s e leg c l o s e
in to identify known l a n d m a r k s a s a i d s i n a c c o m -
plishing alignment. I t i s p o s s i b l e t h a t the b a s e
leg h e s e l e c t e d w a s too c l o s e i n f o r the one tech-
nique and too f a r out f o r the o t h e r . In any event,
alignment was not accomplished.
Although h e failed t o e s t a b l i s h alignment
with Runway 7 he did t u r n to a heading of approx-
i m a t e l y 76 d e g r e e s , p a r a l l e l t o Runway 7, then
l o w e r e d the g e a r and descended. D i s c o v e r i n g
this m i s a l i g n m e n t he e l e c t e d to u s e No. 3 3 ( m i s -
n a m e d No. 31 when informing the tower). He
changed heading t o a p p r o x l m a t e l y 30 d e g r e e s ,
toward the a i r p o r t . B e c a u s e of the extended
g e a r , the unfeathered r i g h t p r o p e l l e r , and the
low a i r s p e e d t h e n r e m a i n i n g , h e w a s unable t o
m a i n t a i n l e v e l flight b u t continued to the a i r p o r t
a r e a , losing altitude a l l the way, and failed t o
c l e a r the l a s t powerline i n h i s path.
Probable Cause
The probable c a u s e of t h i s a c c l d e n t w a s
the c a p t a l n l s i r r e v o c a b l e c o m m i t m e n t t o a land-
ing wlthout r a d l o o r visual confirmation of h i s
runway alignment following engine f a i l u r e i m m e -
diately a f t e r take-off i n n e a r m l n i m u m visibility.
180 ICAO Circular 50 -AN/ 45

PROBABLE F L I G V T P A T H

CURREY A I R TRANSPORT, LTO. N - - 7 4 663

LOCKHEEO A I R TERMINAL
BURBANK, C A L I F .
September 8 , 1955

Encircled numbera rhow locotion of ground witnestes t o approach.

gure 24
~:i
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
No. 42
Associated Airways Limited, B r i s t o l 170 blk. 31, CF-GBT
c r a s h e d n e a r Thorhild, Alberta, on 17 September 1955.
Report No. 55-48 r e l e a s e d by Canadian Department of T r a n s p o r t ,
A i r S e r v i c e s Branch. Civil Aviation Division
Circumstances
At 0021 hours Mountain Standard T i m e the
a i r c r a f t took off f r o m Edmonton for Yellowknife
with a c r e w of 2, 4 p a s s e n g e r s and a c a r g o of
freight.
An IFR flight plan had been filed f o r the
flight to be made a t 5 000 f e e t over Blue AirRoute
No. 84. Clearance out of the Edmonton Control
A r e a was given to the a i r c r a f t but V F R was t o be
maintained while in the a r e a .
About twenty-two minutes a f t e r take-off.
the tower a t ~ a m a h beard a d i s t r e s s message
f r o m the a i r c r a f t indicating that the s t a r b o a r d
engine had failed and that the a i r c r a f t was r e t u r n -
ing to Edmonton a t 3 000 feet. Two minutes later
another d i s t r e s s m e s s a g e was picked up by Namao
stating that the a i r c r a f t was returning to Edmonton.
Two-way communication with the a i r c r a f t was not
established and although Namao and Edmonton
continued to c a l l the a i r c r a f t f o r m o r e than t h i r t y
minutes, nothing f u r t h e r was h e a r d f r o m it. Al-
though hampered by d a r k n e s s and poor weather
conditions, an a i r and ground s e a r c h was s t a r t e d
a l m o s t immediately but without s u c c e s s , until
s h o r t l y a f t e r f i r s t light when the wreckage was
found in a f a r m field about ten m i l e s north of
Thorhild. The pilot-in-command and one pas-
s e n g e r had been killed and the co-pilot and t h r e e
other p a s s e n g e r s were s e r i o u s l y injured. The
a i r c r a f t was destroyed.
T h e r e w e r e no witnesses to the accident
but evidence f r o m the s u r v i v o r s indicated that
the flight had been n o r m a l for about the f i r s t
twenty minutes. At this time the s t a r b o a r d en-
gine began to lose power, m i s s and backfire and
was accompanied by a fluctuation of between 3"-
4" of manifold p r e s s u r e . T h i s condition l a s t e d
about t h r e e o r four minutes. The pilots then
feathered the engine and attempted t o r e t u r n to
Edmonton. O r d e r s w e r e then given to jettison
the c a r g o and the r e a r door was opened and gro-
c e r i e s , s a c k s of s u g a r and flour were thrown out
f o r a period of about ten minutes. It was then
about 0055 hours. The c r e w then stopped jettison-
ing c a r g o and waited for the c r a s h which o c c u r r e d
a l m o s t immediately.
181
After the f a i l u r e of the s t a r b o a r d engine,
the a i r c r a f t lost n e a r l y 3 000 feet of altitude in
about ten minutes and c r a s h e d in the open field,
The s u r v i v o r s could offer no s a t i s f a c t o r y ex-
planation f o r the accident and, a s a r e s u l t of
h i s i n j u r i e s , the co-pilot w a s unable t o give
complete details of what had o c c u r r e d , although
he did r e c a l l that f o r a t i m e he had taken o v e r
control of the a i r c r a f t and flown during the
emergency.
Investigation and Evidence
A Certificate of Airworthiness, to expire
on 22 December 1955, had been i s s u e d f o r the
a i r c r a f t . Subsequently, however, radio equip-
ment had been changed in the a i r c r a f t by the
Company and the a i r c r a f t had not then been
submitted f o r inspection and re-certification
a s should have been done. Moreover, the
weight used by Company d e s p a t c h e r s did not
a g r e e with the weight given in the Weight and
Balance Report accompanying the Certificate
of Airworthiness. In addition, the a i r c r a f t had
been weighed on 17 August 1955, and the t a r e
weight was found to be 28 578 lbs. , which was
1 332 lbs. more than the t a r e weight which
continued t o b e used by Company d e s p a t c h e r s
in computing the all-up-weight although the
r e s u l t s of the reweighing had been known by
Company officials.
As a r e s u l t the computation of the all-
up-weight of the a i r c r a f t showed that it was
overloaded a t the t i m e of the accident by a t
l e a s t 1 4 0 0 lbs.
F u r t h e r , the a i r c r a f t was balanced by
placing i t e m s of equal weight a t the s a m e
distance on each side of a loading line. Thus
the a i r c r a f t had not been loaded in conformity
with the Certificate of Airworthiness.
A modification t o the a i r c r a f t ' s heating
s y s t e m had been made p r i o r t o the flight.
Shortly before the s t a r b o a r d engine failed, a n
attempt was made t o s t a r t the h e a t e r without
s u c c e s s . Almost immediately t h e r e a f t e r the
s t a r b o a r d engine failed. However, no evidence
 182 ICAO Circular 5 0 - ~ ~ / 4 5

could be found to indicate that operation of the a i r c r a f t would be further decreased by the r e a r
heater s y s t e m was responsible f o r the engine door being open while cargo was being jettisoned,
failure.
The weather f o r e c a s t f o r the period 1700
While weather conditions favoured ice hours on 16 September 1955 to 0500 hours on 17
formation, i t was not possible to determine whe- September, indicated that a depression located
ther this was a factor. It i s improbable that ice e a s t of McMurray was remaining stationary and
formed in the carburetor itself since this was an filling slowly. The circulation was north to north
injector carburetor with an o i l heater b a r r e l . It easterly.
was not possible to determine whether ice form-
ed in the a i r scoops to the c a r b u r e t o r but this Northern half of the Edmonton region.
could be considered a possibility in the light of
the weather conditions a t the time of the accident. Clouds and Weather 6 000 feet broken -
l a y e r s 15 000 feet in-
Thorough examination failed to reveal any- termittent light rain
thing that would account for the engine failure. with ceilings 2 500
However, further investigation of both of the feet and visibility 3-6
engines and c a r b u r e t o r s i s being made by the miles in drizzle after
manufacturer. 1900 hours.

A further modification had been made to Icing Light in cloud above

the vacuum selector control. As a result of this freezing level.
modification only the pilot's o r co-pilot's s e t of
gyro-driven instruments would continue to oper- Freezing Level 6 500 feet mean s e a
ate in the event of the failure of one engine. The level.
new operation of the selector control had not been
clearly marked a s should have been done nor had Turbulence Light below 8 000 feet.
the co-pilot been made aware that certain of his
instruments would not be giving accurate indica- Wind and Temperature At 4 000 feet 300' a t
tions due to the f a i l u r e of one engine. 3 5 , 6 " c 310" at30,6c.

Examination of the wreckage and ground a t

the scene of the accident indicated that the a i r -
craft was in a slight turn to the right a t the mo-
ment of impact. This i s substantiated by one of
the crew members who stated that while jettison-
ing the cargo the right wing was down.
Information a s to the performance figures
of this a i r c r a f t shows that on single-engine per-
formance, the a i r c r a f t should not have lost alti-
tude a s rapidly a s i t did. However these per-
formance figures would not apply to an a i r c r a f t
that was overloaded and the performance of the
Probable Cause
F o r reasons not a s yet determined, the
starboard engine failed and a s a r e s u l t of being
overloaded, the a i r c r a f t did not maintain alti-
tude on one engine and s t r u c k the ground with
the starboard wing tip.
A further contributory factor was con-
sidered to be the failure of the co-pilot's vacu-
um-driven gyro instruments, without his knowl-
edge.

ICAO Ref: A R / ~ o ' ?

 ICAO C i r c u l a r 5 0 - ~ N / 4 5 183

No. 4 3

British O v e r s e a s Airways Corporation, Argonaut a i r c r a f t , G-ALHL, c r a s h e d

on landing a t I d r i s A i r p o r t , Tripolitania, United Kingdom of Libya, 21 September 1955.
Report r e l e a s e d 15 October 1955 by Mlnistry of Communications, Libya.

Circumstances weather r e p o r t was made a t the r e q u e s t of

The a i r c r a f t was operating the Rome-Tri-
pol! s e c t o r of a scheduled flight London-Rome-
Trlpoli-Kano and Lagos. The accident o c c u r r e d
during the fourth attempt to land a t night on Run-
way 11 a t Idris A i r p o r t in conditions of strong
wind and poor visibility. During the l a s t approach
the a i r c r a f t s t r u c k t r e e s and c r a s h e d 1 200 y a r d s
s h o r t of runway 11, a t 2223 hours Greenwich Mean
T i m e and f i r e broke out before it c a m e to rest.
Of the 7 c r e w m e m b e r s and 40 p a s s e n g e r s on
board 15 w e r e killed instantly and 21 w e r e injured.
Investigation and Evidence
Air Traffic Control immediately a f t e r the
accident.
N o t f t The Q.N.H. is, briefly, the setting which
if set on the sub-scale of the altimeter ensures that the
instrument indicates height above mean sea level. Thus.
with this setting, when the aircraft lands the altimeter
should indicate the approximate height of the airport above
mean sea level.
The Q.F. E. is, briefly, the setting which if set on
the sub-scale of the altimeter ensures that the instrument
should read approximately zero when the aircraft lands.

The captain and f i r s t officer stated that

throughout the flight and a t the time of the acci- P r i o r to the flight the captain visited
dent t h e r e was no malfunctioning of any p a r t of the Meteorological Office a t Ciampino A i r p o r t ,
the a i r c r a f t , its controls, instruments, engines Rome and obtained a route and t e r m i n a l f o r e -
o r equipment. c a s t f o r the flight to I d r i s A i r p o r t . The
t e r m i n a l f o r e c a s t gave the expected visibility
The Meteorological Office, I d r i s A i r p o r t , a t I d r i s A i r p o r t between 1800 and 2100 hours
issued the following weather r e p o r t s to Air T r a f - a s 16 km. with the possibility of it d e c r e a s i n g
f i c Control during the evening of 21 September. to 6 km. in 'suspended s a n d ' . The wind was
given a s likely to be 120" a t 20 kts. He a l s o
X E WIND SPEED& CLUD WEATHER QNH VISIBILITY
visited the A i r Traffic Control Office a t 1825
DIRECTION
h o u r s and filed a flight plan giving a n elapsed
time f o r the flight to I d r i s A i r p o r t of 3 h o u r s 4
2100 110° 17 kts. No low Rising 1014 mbs. 2 n. m. minutes; h i s endurance was 6 h o u r s 6 minutes
gusting 25 cloud sand 4500 yards and h i s d e c l a r e d a l t e r n a t e a e r o d r o m e s w e r e
Malta, Nice and Naples. The a i r c r a f t took
2205 100° 20 kts. Nil Rising 1012.8 0 . 9 n .m. off a t 1855 h o u r s with a n e s t i m a t e d t i m e of
gusting 27 sand mbs. a r r i v a l a t I d r i s A i r p o r t of 2159 hours. During
the climb, icing conditions w e r e encountered
2224 1200 20 ko. Nil Rising 1012.7 2000yards. and a t one stage power had to be i n c r e a s e d t o
gusting 28 sand mbs. maintain the climb; but a f t e r passing through
the cloud the i c e gradually c l e a r e d and the
The 2205 h o u r s r e p o r t was not transmitted flight proceeded n o r m a l l y t o P a l e r m o , whence
to the a i r c r a f t . It was taken to the Air Traffic Malta Flight Information C e n t r e gave i t a
Control Tower by the Meteorological Observer at d i r e c t c l e a r a n c e t o I d r i s A i r p o r t a t 18 000 feet.
2209 h o u r s a t which t i m e the Approach Controller The weather f o r the r e m a i n d e r of the flight
on duty was speaking to the a i r c r a f t . The Aero- was 'fine'. During the whole of the flight and
d r o m e Controller was out by the runway with a during t h e l a p p r o a c h e s to I d r i s A i r p o r t u l t r a -
Very light pistol r e a d y to a s s i s t the a i r c r a f t by violet and dimmed r e d lighting w e r e used to
firing signal c a r t r i d g e s . The A i r Traffic Control illuminate the a i r c r a f t i n s t r u m e n t s .
C l e r k was t e m p o r a r i l y absent. The Meteorologi-
c a l O b s e r v e r , therefore, left the r e p o r t on the Approximately 90 miles f r o m Tripoli,
Aerodrome Controllerls d e s k and i t was not s e e n a t 2137 hours, the a i r c r a f t began to communi-
until a f t e r the accident. The 2224 hours cate d i r e c t on VHF/RT with I d r i s A i r p o r t
184 ICAO Circula
Approach Control on a frequency of 119.7 m/cs.
It was given c l e a r a n c e f o r an u n r e s t r i c t e d de-
s c e n t and flight to the a i r p o r t , and was r e q u e s t -
ed to r e p o r t both when i t was abearn Wheelus
F i e l d and when it had I d r i s A i r p o r t in sight. The
a i r c r a f t c r o s s e d the Libyan c o a s t a t an altitude
of 7 500 f e e t and when c l e a r e d t o d e s c e n d below
4 500 f e e t i t r e c e i v e d Prom I d r i s A i r p o r t the
weather r e p o r t f o r 2100 h o u r s . The a i r c r a f t was
a l s o informed that two runways, 11 and 18, w e r e
available. The captain elected t o land on runway
11 a s he knew that t h e r e would be a s t r o n g c r o s s -
wind on 18. He a l s o considered t h a t h ~ landing s sending someone t o the t h r e s h o l d of runway
weight of approximately 71 000 l b s . , together
with the s t r o n g wind blowing down runway 11
would e n s u r e that the length of t h a t runway
(1 600 y a r d s ) would b e m o r e than sufficient. On
a previous occasion in a s t r o n g wind he had land-
ed on runway 11 without having to u s e p r o p e l l e r
braking. He was fully a w a r e that t h e r e w e r e no
lead-in o r approach lights to runway 11 which was
equipped with an e l e c t r i c f l a r e path with 4 sodium
lights a t each end. Auxiliary gooseneck lighting
had a l s o been laid along i t e a r l i e r that night.
The a i r c r a f t approached I d r i s A i r p o r t a t
2 000 f e e t a t approximately 2200 h o u r s . The a i r - settings on t h e i r a l t i m e t e r s (implying that
p o r t lights could b e s e e n f r o m t h i s height but not
the a c t u a l runway lights. The a i r c r a f t commenc- t h e i r height above the runway). The captain
ed a left-hand c i r c u i t and flew t o the south of the
airfield. A d e s c e n t was made t o 1 200 f e e t QNH,
and the flaps w e r e lowered to 15 '. Both the cap-
tain and the f i r s t officer had the 2100 h o u r s QNH
s e t on t h e i r a l t i m e t e r s . The a i r c r a f t flew towards to k e e p a c l o s e look-out f o r the runway lights
the downwind o r w e s t e r n end of runway 11; a s i t
c a m e a b e a m of the runway a t 1 200 f e e t the cap-
tain could s e e the runway lights. He flew down-
wind f o r 1 minute but before turning l e f t o n t o
b a s e leg he l o s t sight of the lights. He t u r n e d on
t o b a s e l e g slowly descending in the t u r n to 650
f e e t QNH which height he then maintained with
power settings of 48 inches of manifold p r e s s u r e
and 2 650 r . p . m . A s the a i r c r a f t c a m e round on
to a heading of 110' h e s a w the runway lights again m i n i m u m f o r landing a t I d r i s A i r p o r t a t night
but he was then 300 y a r d s t o the left of the run-
way. It was i m p o s s i b l e t o a t t e m p t a landing and
the captain decided to overshoot and c a r r y out
another c i r c u i t (time-2206 h o u r s ) . During this
f i r s t c i r c u i t considerable turbulence was expe-
r i e n c e d which m a d e good i n s t r u m e n t flying diffi-
c u l t and t h i s was p a r t i c u l a r l y s o t o the w e s t of
the a i r p o r t .
The captain went through the s a m e c i r c u i t
p r o c e d u r e again with s i m i l a r r e s u l t s , except that m o r e s e v e r e turbulence t o the w e s t of t h e a i r -
on this second c i r c u i t the a i r c r a f t a r r i v e d slight-
ly n e a r e r the runway on i t s f i n a l approach. On
this second and subsequent c i r c u i t s the captain
was given VEIF/DF r a d i o b e a r i n g s t o help h i m
line-up with the runway. The captain h a s s a i d
that a f t e r t h e s e two unsuccessful a p p r o a c h e s
he was not a t a l l a p p r e h e n s i v e about continuing
to a t t e m p t to land on runway 11. He f e l t h i s
only difficulty was i n lining up with the runway
in t h e poor visibility. He e s t i m a t e d that a t
the t i m e of h i s second o v e r s h o o t h e could
spend a f u r t h e r 30 minutes o v e r I d r i s A i r p o r t
without encroaching on the fuel r e s e r v e neces-
s a r y t o take h i m t o his f i r s t a l t e r n a t e a e r o -
d r o m e - Malta. After the second overshoot
( t i m e 2210 h o u r s ) the a p p r o a c h c o n t r o l l e r told
the captain he would a s s i s t h i m t o line-up b y
11 with a V e r y light pistol to f i r e lights a s the
a i r c r a f t made i t s f i n a l approach.
On the t h i r d c i r c u i t , the a i r c r a f t was
b e t t e r aligned with the runway but b y the t i m e
the runway lights w e r e sighted it was too high
and too c l o s e in f o r the captain to a t t e m p t 3
landing. He t h e r e f o r e took o v e r s h o o t action
again ( t i m e - ~ 2 1 8h o u r s ) and flew low up the
runway to a s s e s s f o r himself the visibility
conditions f o r landing. During the low l e v e l
r u n up the runway, the f i r s t officer r e m i n d e d
the captain that they w e r e flying with QNH
t h e i r a l t i m e t e r s did not t h e r e f o r e indicate
r e p l i e d to the effect that he w a s a w a r e of this.
He decided t o c a r r y out a low visibility run-
way a p p r o a c h p r o c e d u r e and c l i m b e d t o 1 300
feet. The captain i n s t r u c t e d t h e f i r s t officer
during t h e p r o c e d u r e t u r n s of the runway ap-
p r o a c h procedure. T h e up-wind t i m e d t u r n w a s
completed a t a height of about 1 300 f e e t QNH,
and before the a i r c r a f t commenced i t s down-
wind r u n the whole length of the runway lights
could be s e e n . T h i s indicated that t h e visibil-
ity was then a t l e a s t 1 600 y a r d s which was
well above B. 0. A. C. 1s m i n i m u m visibility
f o r landing. (Note: B. 0. A. C. Is visibility
on a l l runways i s 1 0 0 0 y a r d s ; the c r o s s w i n d
component m u s t not exceed 26 knots. T h i s
m i n i m u m a n d this m a x i m u m a r e contained in
the C o r p o r a t i o n ' s Operations Manual). As the
a i r c r a f t approached t h e downwind threshold of
runway 11 a t 1 200 f e e t the captain turned 45 O
to t h e right, t u r n e d back 10 O - 15 O t o c o r r e c t
f o r d r i f t , and then continued on the new head-
ing f o r 45 seconds b e f o r e commencing a t u r n
to the left. Again the a i r c r a f t encountered the
field. During t h i s t u r n the captain reduced
power and gradually descended to 650 f e e t
QNH; a f t e r i t s completion, in o r d e r t o main-
tain height at 125 - 130 knots, he i n c r e a s e d
power f i r s t to 5 2 inches manifold p r e s s u r e
 ICAO Circular 5 0 - ~ N / 4 5
and then reduced this to 48 inches. During the
procedure turn the f i r s t officer had completed
the landing check which included lowering the
undercarriage.
Shortly after the completion of the turn,
the f i r s t officer reported 'runway ahead1 and the
captain looked a t his altimeter and saw that it
was indicating 610 feet (i. e. about 350 feet above
the level of the runway). Having a c l e a r view of
the lights he decided to make a visual approach
and reduced power to 40 inches using this setting
because of strong wind conditions and the neces-
sity of making a flat approach. He considered
that he would have to do a slight turn to port to
line-up with the runway and he estimated that it
was about a mile ahead. Shortly a f t e r commenc-
ing the visual approach, he was about to call f o r
the f i r s t officer to switch on the landing lights
when he partially lost sight of the runway lights
and saw what he thought to be a cloud of billow-
ing sand. Having lost his visual reference he
reverted to instrument flying and perturbed by
what he saw reached f o r the throttles to climb.
At that moment the f i r s t officer called "Look
out. Climb1I, and simultaneously the a i r c r a f t
shuddered and a s e r i e s of impacts followed. The
a i r c r a f t crashed through lines of t r e e s , hit the
ground, and c a m e to r e s t on f i r e in a n olive grove.
The whole a i r c r a f t was ablaze within two
minutes. The majority of the passengers who
survived escaped through the starboard e m e r -
gency exits, and the crew escaped through the
crew door on the starboard side of the flight deck.
The f i r s t vehicles f r o m Idris Airport F i r e
Service reached the scene of the accident approx-
imately 7 minutes after the c r a s h . They took a
route made difficult by soft sand dunes through
olive groves directly a c r o s s country f r o m where
they had been stationed in readiness adjacent to
runway 11. By the time they a r r i v e d much of the
s t r u c t u r e of the a i r c r a f t had been consumed by
f i r e , and a l l survivors were out of the aircraft.
The f i r e party immediately concentrated on putt-
ing out the fire. Shortly afterwards, a l a r g e
number of Royal Air F o r c e personnel f r o m the
R. A. F. Station a t Idris Airport a r r i v e d and to-
gether with the Airport F i r e Service personnel
rendered a l l possible assistance to the survivors,
some of whom were seriously injured. They
a l s o made a linked-arm s e a r c h in the darkness
and flying sand f o r possible missing survivors.
Inspection a t the scene of the accident
showed that the a i r c r a f t had crashed on a soft,
sandy cultivated a r e a to the west of Idris Airport
about 1 200 y a r d s s h o r t of the threshold and 485
185
yards to the left of the extended centre line of
runway 11. The ground a t this point i s 12 feet
below the level of the threshold of runway 11.
The initial impact was with lines of
eucalyptus t r e e s bordering a narrow unmade
road running east-west. These t r e e s varied
in height between 28 and 42 feet and had been
cut off about 20 feet f r o m the ground over a
distance of 168 feet. The appearance of the
gap s o formed in the lines of t r e e s suggested
that the a i r c r a f t was approximately laterally
level a t the moment of impact.
Commencing 185 feet beyond the line of
t r e e s was a s e r i e s of three r u t s made by the
landing gear of the a i r c r a f t . These r u t s were
on a heading of 130' and a line joining them
with the point of impact with the t r e e s indicated
that the a i r c r a f t ' s angle of descent was about 4'.
About 400 feet beyond the initial impact
with the t r e e s , the a i r c r a f t c r o s s e d a second
tree-lined sunken road running north-south.
A gap 105 feet wide was torn in this second
double line of t r e e s ; the t r e e s a t the left-hand
side cff the gap were cut 25 feet f r o m the ground,
and the t r e e s a t the right-hand side of the gap
a t 10 feet f r o m the ground.
The right main and nose landing g e a r
were torn out of the a i r c r a f t s t r u c t u r e on f i r s t
impact with the ground and this caused the right
wing to drop and drag the ground resulting in
the breaking away of the two right propellers.
The right wing was torn away f r o m the a i r c r a f t
a t about this point and i t s f u r t h e r disruption
was the r e s u l t of passing through the t r e e s
lining the second road. The a i r c r a f t which had
already commenced to yaw to the right, was
slewed round still further a s a result of the
right wing dragging the ground and breaking
away s o that i t passed sideways through the
t r e e s lining the second road with the left wing
leading.
The fuselage and left wing finally came
t o r e s t about 550 feet beyond the f i r s t point of
impact with the t r e e s , the fuselage having
slewed round 90' to the right.
Both left propellers had broken off a t
their reduckion gear casings and lay between
the second road and the main wreckage. The
left wing had been torn off a t the root, and lay
parallel to the fuselage, and close to it. It
was inverted and with the wingtip towards the
tail. The left main landing g e a r lay burnt-out
in the inner wing, having folded inwards.
186 ICAO Circular 50-AN/45
Both left engines had broken away f r o m
the wing; the outer engine having been driven
inwards lay burnt-out in the remains of the wing
leading edge. The inner engine had become de-
tached f r o m the wing and had a l s o been driven
inwards and lay burnt-out in the remains of the
fuselage. When the a i r c r a f t was travelling side-
ways with the left wing leading, the wing broke
away a t the root and turned over. This led to
the detachment of the propellers and the breaking
away of the engines in an inward direction. The
detached left wing, engines, and fuselage trav-
elled forward together and a s they came to r e s t ,
the left inner engine was driven up into the fuse-
lage f r o m below floor level. The floor of the
forward passenger cabin must have been consid-
erably displaced upwards and this resulted in
the death o r injury of the majority of the occu-
pants.
F i r e broke out before the a i r c r a f t had
c r o s s e d the second road and the f i r s t evidence
of burning was in the wreckage t r a i l about 220
feet beyond the initial impact with the t r e e s . At
the time of the c r a s h the a i r c r a f t held about 600
gallons of fuel distributed between the main
tanks. On f i r s t impact with the t r e e s , the inte-
g r a l tanks in the wings of the a i r c r a f t were t o r n
open thus releasing quantities of fuel which be-
came ignited before the a i r c r a f t came to r e s t .
The detached left and right wings were severely
burnt and the fuselage had been almost complete-
ly destroyed. The exceptionally s e v e r e f i r e
damage was due to the fact that the fuselage
came 40 r e s t close alongside and on the down-
wind side of the left wing which contained about
300 gallons of fuel. The rapid outbreak of f i r e
within the fuselage was due to the fact that the
left side of the fuselage had been torn open by
the left inner engine thus providing entry to the
f i r e already s t a r t e d a t the left wing.
Examination of the wreckage showed that
a t the time of impact the landing gear was fully
extended and the flaps partially extended. Due
to impact damage i t was not possible to deter-
mine the p r e c i s e flap angle but it has been estab-
ished that it could not have been l e s s than 10'.
- -
The condition of the propellers indicated that the
engines were developing power a t impact, and
examination of their pitch change mechanisms
showed that they wer; a l l s e t a t the fine pitch
end of the normal constant speed range. There
was no evidence that any mechanical failure of
the engines had occurred prior to impact. No
evidence was found which would suggest any
malfunctioning of the flying control circuits.
The remains of the captain's altimeter were
recovered and by comparison with a s i m i l a r
instrument it was established that the millibar
scale was s e t at 1014. The remains of the
f i r s t officer's altimeter were recovered, but
it had been s o severely damaged by f i r e that
its setting could not be established. The pitot/
static s y s t e m had been completely burnt out
and i t was not possible to c a r r y out any check
of the s y s t e m o r to establish whether it was
selected to normal o r alternate source.
A total of 6 emergency exits a r e provided
in an Argonaut, 3 on each side of the fuselage.
There a r e 4 of these exits in the front passen-
g e r cabin and 2 in the r e a r . The mechanism
of the c e n t r e emergency exit on the left hand
side was found in the closed position. The
remains of the other emergency exits were not
identified.
No useful evidence was obtained f r o m
the remains of the passenger s e a t s ; they had
been so badly burned that only the s t e e l com-
ponents remained. The floor of the passenger
cabins had a l s o been consumed s o that it was
impossible to a s s e s s the behaviour of the s e a t
s t r u c t u r e s during the c r a s h .
The remains of the c r e w door were found
with i t s operating mechanism in the open position.
The main passenger door had been completely
destroyed by f i r e and the position of its operat-
ing mechanism could not therefore be determined.
The a i r c r a f t ' s automatic c r a s h f i r e extin-
guishing s y s t e m had operated but the discharge
of extinguishing media had little effect on the
outbreak of f i r e which was remote f r o m the
a r e a s covered by the installation.
The captain's decision to use runway 11
was justifiable. A civil DC-6 a i r c r a f t landed
without difficulty on this runway in s i m i l a r
conditions approximately 1 hour after the acci-
dent, Although the cross-wind component on
the long runway 18 was l e s s than the Corpora-
tion's permissible maximum i t was sufficiently
strong t o warrant the rejection of that runway
in favour of the s h o r t e r runway 11. However,
having failed on three occasions to line-up and
land on runway 11, it i s considered that the
captain should have revised his decision not to
use runway 18 which had b e t t e r approach aids
namely, lead-in lights, a locator beacon, and
the VHF/DF m o r e favourably positioned.
During the.fina1 procedure turn, the
captain gradually reduced height f r o m about
1 200 feet to 650 feet QNH. The undercarriage
was lowered in the turn. On the completion of
the turn the captain increased power to check
his descent and maintain height, and almost
 ICAO Circular 5 0 - ~ N / 4 5
immediately afterwards the f i r s t officer report-
ed 'runway ahead1. The captain noticed a t that
moment that his altimeter was indicating 610
feet. H e immediately reduced power to com-
mence a visual approach and descent. The con-
ditions were turbulent which made accurate fly-
ing difficult. Within a s h o r t space of time - a
few seconds - the captain saw the billowing
sand ahead and the a i r c r a f t struck the t r e e s
before he could climb. The height of the ground
where the a i r c r a f t struck the t r e e s i s 243 feet
above mean sea level, which i s 12 feet below the
level of the threshold of runway 11. This indi-
cates that the a i r c r a f t lost approximately 350
feet in a s h o r t space of time. It would appear,
therefore, that the a i r c r a f t ' s descent was never
fully checked a f t e r the completion of the proce-
dure turn, and that the r a t e of descent increased
after the captain reduced power to make his
visual approach. It i s significant that after
noting the 610 feet and after commencing his
viS11alapproach the captain apparently did not
r e f e r again to his altimeter. It i s apparent that
he did not realize that his approach path had
become too steep and the a i r c r a f t was becoming
dangerously low;
The use of a QNH altimeter setting means
that in o r d e r to obtain the true height above the
aerodrome a pilot must subtract the known
altitude of the aerodrome f r o m the altitude in-
dicated by h i s altimeter. When a QE'E setting
i s used the height above the aerodrome i s read
directly off the instrument. A pilot must, there-
f o r e , be quite c l e a r in his mind whether he has
a QNH o r Q F E setting. The Board has consider-
ed the possibility that the captain having a QNH
setting on his altimeter treated i t on the final
approach a s a Q F E setting; and, indeed, this
would appear to be the most logical explanation
of the accident. The captain stated that he had
on occasions used a Q F E setting for landings.
However, on the overshoot after the third attempt
to land, the f i r s t officer reminded the captain
that he was flying with a QNH setting on his alti-
m e t e r and the captain confirmed that he was
aware of this. The captain, therefore, appeared
to be fully aware of the type of setting he had on
his a l t i m e t e r , and in the absence of further
ICAO Ref: A ~ / 4 2 0
187,
evldence to the contrary the Board must accept
that he made his final approach with no confusion
in his mind a s to the type of a l t i m e t e r setting he
was using.
The Board i s aware of the circumstances
which led to the non-transmission of the 2205
hours weather report, which included a reductlon
of 1.2 mbs. in the QNH. Had the captain receiv-
ed the amended QNH and made the adjustment to
his altimeter, it i s assumed that he would have
c a r r i e d out his instrument procedures approxi-
mately 30 feet higher, but it i s considered that
this adjustment would have had little effect on
his visual final approach. Consequently, whilst
the omission to t r a n s m i t this report cannot be
condoned, the Board considers that an adjust-
ment of 1 mb. during his attempts to land would
not have materially affected the course of events.
The a i r c r a f t crashed 1 2 0 0 y a r d s short of the
runway on ground that i s 12 feet below the level
of the runway threshold whilst i t was descending
at a relatively steep angle. At this distance
f r o m the runway, assuming a 2 1/20 glide path
and a touch-down point 100 yards up the runway,
the a i r c r a f t should have been a t l e a s t 170 feet
above the ground.
The t r e e s s t r u c k by the a i r c r a f t in no way
constituted an obstruction to the runway ( a s
defined in ICAO Annex 14, part 5, Chapter 1,
para. 1).
Probable Cause
The accident was the r e s u l t of a n e r r o r
of judgement on the part of the captain who hav-
ing made three unsuccessful attempts to line-up
and land on runway 11 on his fourth attempt
allowed his d e s i r e to keep the runway lights in
view to affect his judgement, in that during a
visual approach to the runway he failed to make
adequate reference to his flight instruments. In
the r e s t r i c t e d visibility the runway lights gave
him insufficient guidance a s to attitude, height
and angle of approach and unknowingly he per-
mitted the a i r c r a f t to descend below i t s c o r r e c t
approach path.
 188 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5

No. 44

G r e a t L a k e s C a r b o n C o r p o r a t i o n , Douglas A-26-C, c r a s h e d
following s t r u c t u r a l f a i l u r e resulting f r o m a m i d - a i r explosion
n e a r Union C i t y , Oklahoma, on 3 October 1955.
Civil A e r o n a u t i c s B o a r d ( USA ) Accident Investigation R e p o r t
F i l e No. 2-0058 r e l e a s e d 29 F e b r u a r y 1956.

Circumstances
T h e a i r c r a f t d e p a r t e d B r i d g e p o r t , Con-
necticut, f o r California a t 1245 h o u r s C e n t r a l
S t a n d a r d T i m e c a r r y i n g two c r e w m e m b e r s .
Two s t o p s w e r e then m a d e a t White P l a i n s , N . Y.
and a t L a G u a r d i a F i e l d w h e r e 2 p a s s e n g e r s
boarded t h e a i r c r a f t . A t 1346 the flight left L a
G u a r d i a f o r T u l s a , Oklahoma, under Visual
F l i g h t R u l e s and no flight plan w a s filed. A t Tul-
s a the a i r c r a f t w a s refuelled with 906 gallons of
gasoline which filled t o c a p a c i t y both m a i n tanks,
t h e n o s e tank and the r e a r f u s e l a g e tank. A f t e r
the pilots w e r e b r i e f e d by the T u l s a U.S. Weath-
e r B u r e a u Office, a n I n s t r u m e n t F l i g h t R u l e s
flight plan w a s f i l e d with the A i r Route T r a f f i c
C e n t r e . A t 21 14 Oklahoma C i t y A i r w a y Commu-
nications Station r e c e i v e d a c a l l f r o m the flight
on 126. 7 m c s . requesting cancellation of the
I F R flight plan and asking f o r a landing c l e a r a n c e
a t Oklahoma City. T h e flight w a s given the
s p e c i a l 2100 w e a t h e r a s 10 000 f e e t o v e r c a s t ,
s k y p a r t i a l l y o b s c u r e d , fog. visibility 1-1/2 miles,
and w a s advised t o contact RAPCON ( R a d a r
A p p r o a c h Control) on 119.3 m c s . f o r a c l e a r -
a n c e t o Iand a s IFR conditions prevailed, T h e
c r e w a d v i s e d t h a t i t d e s i r e d c l e a r a n c e f o r Will
R o g e r s F i e l d . T h i s w a s the l a s t r a d i o c o n t a c t
with the a i r c r a f t . I t c r a s h e d a t 2117 h o u r s 2-
- 3/8 m i l e s n o r t h w e s t of Union C i t y , Oklahoma,
and 23 m i l e s w e s t of Will R o g e r s F i e l d , Okla-
homa City. Two explosions w e r e h e a r d in the
a i r p r i o r t o t h e c r a s h and p o r t i o n s of the e m -
pennage and f u s e l a g e w e r e found along the l a s t
3 m i l e s of the flight path. T h e r e w e r e no s u r -
vivors.
Investigation a n d Evidence
W i t n e s s e s s e v e r a l m i l e s n o r t h of the
c r a s h s i t e , who o b s e r v e d the a i r c r a f t s e v e r a l
hundred f e e t above the ground, d e s c r i b e two
d i s t i n c t f l a s h e s i n i t s d e s c e n t t o t h e ground.
T h e y a l s o mention a light r a i n a t the t i m e but
no lightning.
Examination of the wreckage and ground
m a r k s indicated that t h e a i r c r a f t , m i n u s the a f t
fuselage and t a i l a s s e m b l y , had dived t o the
g r o u n d , in a n inverted attitude a t nose-down
a n g l e of a p p r o x i m a t e l y 45 d e g r e e s on a south-
e a s t e r l y heading.
D i s i n t e g r a t i o n in flight w a s indicated
by n u m e r o u s s e g m e n t s of the fuselage s h e l l
a n d p o r t i o n s of the h o r i z o n t a l s t a b i l i z e r skin
being found back along the flight path a s f a r a s
t h r e e m i l e s f r o m the m a i n wreckage. The
m a i n portion of the empennage w a s found
t h r e e - e i g h t h s of a m i l e f r o m t h e m a i n w r e c k -
age. All of the s c a t t e r e d p o r t i o n s of f u s e l a g e
s t r u c t u r e w e r e f r o m t h e a r e a a f t of t h e cabin
r e a r bulkhead.
Examination of t h e s e p a r t s gave evi-
d e n c e of i n t e r n a l explosive f o r c e s t h a t had
blown t h e skin outward o r off and d i s t o r t e d
the s t r u c t u r e of a l l empennage components
e x c e p t the r u d d e r and the e l e v a t o r s . T h e r e
w e r e no indications of h e a t d a m a g e o r fatigue
in the a f t f u s e l a g e wreckage which could have
r e s u l t e d i n f a i l u r e under loads l e s s t h a n de-
s i g n . T h e r e w a s no c o m p r e s s i o n buckling of
t h e skin and s t r i n g e r s , c h a r a c t e r i s t i c s of fail-
u r e s due t o o v e r l o a d . However, t h e r e w e r e
n u m e r o u s indications of the aft fuselage s h e l l
having d i s i n t e g r a t e d b e c a u s e of e x c e s s i v e
t e n s i l e s t r e s s e s throughout the e n t i r e s h e l l
acting both longitudinally and p e r i p h e r a l l y a t
t h e s a m e t i m e . The f u s e l a g e d i s i n t e g r a t e d
along r i v e t s e a m s , which a r e a r e a s of l e a s t
t e n s i l e s t r e n g t h , evidencing a p r a c t i c a l l y
u n i f o r m i n t e r n a l p r e s s u r e throughout t h e a f t
portion of the f u s e l a g e . The a i r c r a f t w a s not
equipped f o r c a b i n p r e s s u r i z a t i o n .
No evidence w a s d i s c l o s e d t o s u g g e s t
f a i l u r e o r malfunctioning of the engines o r
propellers p r i o r to impact.
Examination r e v e a l e d s c o r c h e d edges
a t t h e t o r n h o l r s i n t h e r u d d e r fabric. B l i s -
t e r e d paint w a s likewise noted a t t h e t r a i l i n g
edge of t h e l e f t elevator. The s o u r c e of t h i s
f l a m e d a m a g e w a s not a s s o c i a t e d with the
ground f i r e .
D e s t r u c t i o n of the a i r c r a f t f o r w a r d of
the cabin aft bulkhead b y ground f i r e w a s
 ICAO C i r c u l a r
extensive. Major components, including wlngs,
f l a p s , a i l e r o n s , nose and cockpit a r e a s , controls,
i n s t r u m e n t s , fuel t a n k s , landing g e a r , n a c e l l e s ,
e t c . , w e r e a l l accounted f o r in the a r e a adja-
c e n t t o t h e point of i m p a c t . Examination d i s -
c l o s e d t h a t the wing f l a p s and the landing g e a r
w e r e in the r e t r a c t e d position a t the t i m e of
impact.
Only the following i n s t r u m e n t readings
w e r e obtainable: Omni B e a r i n g S e l e c t o r 232 d e -
g r e e s ; Radio Magnetic Indicator - double point-
e r 240 d e g r e e s , single pointer (ADF) 198 d e -
g r e e s ; Z e r o R e a d e r S e l e c t o r 240 d e g r e e s ; C2
G y r o C o m p a s s 246 d e g r e e s .
A 125 - gallon fuel tank and r a d i o r a c k
w e r e installed in the aft fuselage without a va-
p o r s e a l s e p a r a t i n g t h e two units. The s e v e r e
f i r e damage a f t e r ground i m p a c t precluded a
d e t e r m i n a t i o n of the condition of the fuel s y s t e m
components p r i o r t o the accident. The aft fuse-
lage fuel tank vent line w a s found with i t s end
iittings failed f r o m e x c e s s i v e tension. The
T u l s a fuel attendant s t a t e d the tank was not o v e r -
filled a t the t i m e of s e r v i c i n g .
In the t a i l section of the f u s e l a g e , aft of
the r e a r cabin bulkhead, i n addition t o the 125-
gallon fuel tank, t h e r e was installed the follow-
ing e l e c t r i c a l equipment: (2) ARN-7 c o m p a s s ;
(2) loop antenna; (1) MN5 3B m a r k e r receiver;
(1) ARN5A glide path r e c e i v e r ; (1) RTA-1B
c o m m a n d unit; (1) A-12 gyrosyn r e p e a t e r a m -
plifier; (2) Collins 51R, (2) Collins 17L-2VHF
t r a n s m i t t e r ; (2) i n v e r t e r s ; (1) isolation a m p l i -
f i e r ; (1) R-89B glide path and (1) BC733D local-
izer.
T h e m o s t r e c e n t a i r f r a m e 100-hour i n s -
pection w a s dated 8 S e p t e m b e r 1955, and the
a i r c raft had flown 14 h o u r s s i n c e that t i m e . T h i s
inspection c o v e r e d the s e c u r i t y of the i n t e r i o r
equipment, such a s t a n k , r a d i o , a l l l i n e s , cables,
and A-12 s e r v o s of the empennage and t a i l c o m -
p a r t m e n t . The l a s t line inspection, a t L a G u a r -
d i a o n 3 October 1955 revealed n o d i s c r e p a n -
cies.
A f t e r the accident a flight check of the
ground navigational f a c i l i t i e s involved i n a n
a p p r o a c h t o Oklahoma City d i s c l o s e d n o r m a l
operation of a l l units.
The a i r c r a f t had b e e n modified f o r p a s -
s e n g e r c a r r y i n g and w a s then c e r t i f i c a t e d by
the Civil A e r o n a u t i c s Administration in the
limited c a t e g o r y which prohibits the c a r r y i n g
of p a s s e n g e r s f o r h i r e . The work included the
following i t e m : No. 15. Installed A r m y type
125-gallon fuel tank in aft sectionof fuselage
(original installation).
According t o r e c o r d s of t h e G r e a t
L a k e s C a r b o n C o r p o r a t i o n Aviation D e p a r t -
m e n t , a l l A i r F o r c e Technical O r d e r s f o r
the A-26 had been r e c e i v e d and compliance
had been a c c o m p l i s h e d .
F a c t s d e t e r m i n e d by investigation d i s -
c l o s e d t h a t the t a i l s u r f a c e s and f u s e l a g e a f t
of the bulkhead a t the r e a r end of the cabin
s e p a r a t e d f r o m the a i r p l a n e i n flight.
The m a n n e r in which the skin bulged
outward and s e p a r a t e d f r o m the horizontal
s t a b i l i z e r s and bulged outward on the fin
could r e s u l t only f r o m v e r y high i n t e r n a l
p r e s s u r e s . It i s a p p a r e n t t h a t the p r e s s u r e s
which c a u s e d t h e disintegration built up sud-
denly and that they originated in the aft fuse-
lage. Only a n explosion within the aft f u s e -
lage could c a u s e a sudden p r e s s u r e i n c r e a s e
of t h i s n a t u r e .
Explosions f r o m c o n c e n t r a t e d s o u r c e s ,
s u c h a s s t i c k s of dynamite o r c o n t a i n e r s of
T N T , produce s e v e r e s h a t t e r i n g and f r a g m e n -
tation c l o s e t o t h e s o u r c e of explosion with
d e c r e a s i n g fragmentation a s d i s t a n c e f r o m the
s o u r c e i n c r e a s e s . T h i s type of explosion a l s o
l e a v e s soot-like d e p o s i t s on the s t r u c t u r e
s h a t t e r e d . Neither of t h e s e c h a r a c t e r ~ s t i c s
w a s p r e s e n t in t h i s c a s e . I n s t e a d , t h e f u s e -
lage disintegration indicated a p r a c t ~ c a l l y
uniform p r e s s u r e s u c h a s i s c a u s e d by the
i g n i t ~ o nof an a i r - g a s o l i n e m i x t u r e which i s
much s l o w e r than the detonation of high ex-
plosives. In addition, t h i s l a t t e r type of ex-
plosion d o e s not leave d e p o s i t s on the s t r u c -
ture. The B o a r d , t h e r e f o r e , concludes t h a t
f u m e s c a u s e d by leaking fuel w e r e Ignited by
o p e r a t i o n of e l e c t r i c a l equipment installed i n
the aft fuselage.
The s c o r c h e d f a b r i c and b l i s t e r e d paint
on the t a i l c o n t r o l s u r f a c e s a p p e a r t o have
b e e n c a u s e d by m o m e n t a r y burning of fuel
which s p u r t e d out of the aft f u s e l a g e tank
a f t e r the f i r s t explosion d i s r u p t e d the fuel
l i n e s . T h i s fuel d r e n c h e d the t a i l s u r f a c e s
while t h e t a i l a s s e m b l y w a s s t i l l attached t o
t h e m a i n p a r t of the a i r c r a f t by m e a n s of con-
t r o l c a b l e s . T h i s s a m e fuel w a s probably
ignited b y isparks f r o m d i s r u p t e d w i r e s of t h e
e l e c t r i c a l equipment i n t h e a f t f u s e l a g e which
could well account f o r the second explosion
d e s c r i b e d by ground w i t n e s s e s .
The n a t u r e of the a c c i d e n t and the f a c t
t h a t a l l c o m m u n i c a t ~ o n sf r o m the flight w e r e
routune and conducted In a n o r m a l tone of voice
190 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5
indicate t h a t the pilots w e r e unaware of a n i m -
mediate e m e r g e n c y . The r e a s o n f o r discontin-
uing the flight t o California and the d e c i s i o n t o
land a t Oklahoma City could not be d e t e r m i n e d .
A s a r e s u l t of the investigation the B o a r d
r e c o m m e n d e d t o the Civil A e r o n a u t i c s Adminis-
t r a t i o n t h a t a l l o w n e r s and o p e r a t o r s of A-26-B
and A-26-C a i r c r a f t b e i m m e d i a t e l y a d v i s e d of
the possible f i r e and explosion h a z a r d s i n h e r e n t
i n s i m i l a r i n s t a l l a t i o n s and t h a t c o r r e c t i v e
action b e taken immediately. Accordingly. the
following notification w a s f o r w a r d e d t o a l l Avia-
tion Safety D i s t r i c t Offices, and t o a l l o w n e r s
of t h i s model a i r c r a f t : "Investigation r e c e n t
A-26 accident i n d i c a t e s possible f i r e and explo-
s i o n h a z a r d i n r e a r fus'elage a r e a . F o r a l l
ICAO Ref: ~ ~ / 4 1 6
A-26-B and A-26-C a i r c r a f t having r e a r fuse-
lage tank i n s t a l l e d in s a m e c o m p a r t m e n t with
e l e c t r i c a l components liable t o s p a r k i n g the
following r e s t r i c t i o n i s m a n d a t o r y until f u r t h e r
notice: R e a r fuselage f u e l tank s h a l l be d r a i n -
e d , purged, and m a r k e d t o prohibit u s e . P l a c -
a r d cockpit fuel c o n t r o l s and f i l l e r c a p f o r in-
f o r m a t i o n pilot and s e r v i c i n g personnel." T h i s
notice w a s followed by AD 55-26-1 which s p e -
c i f i e s modifications f o r reactivation of the r e a r
fuselage tank.
Probable Cause
The probable c a u s e of t h i s a c c i d e n t was
the l o s s of the a i r c r a f t ' s empennage a s a r e -
s u l t of a n inflight fuel explosion i n the a f t s e c -
tion of the fuselage.
 ICAO C i r c u l a r 50-AN/45 191

No. 45

Jugoslowenski A e r o - T r a n s p o r t , Convair CV-340, YU-ADC,

c r a s h e d on the northwest slope of the Kahlenberg, 25 k m . f r o m
Wien-Schwechat A i r p o r t , A u s t r i a on 10 October 1955.
R e p o r t r e l e a s e d by the Accident Investigation Commission, Civll Aviation -- Office,
F e d e r a l M i n i s t r y of T r a n s p o r t and Nationalized Industries ,
&%$ria, on 14 J a n u a r y 1956

Circumstances T h e following weather r e p o r t s and f o r e -

The flight d e p a r t e d B e l g r a d e A i r p o r t in
c l e a r w e a t h e r a t a p p r o x i m a t e l y 1230 h o u r s
Greenwich Mean T i m e e n route t o Vienna c a r r y -
ing 25 p a s s e n g e r s and a c r e w of 4. At 1425
h o u r s the a i r c r a f t w a s t r a n s f e r r e d by a r e a con-
t r o l t o Vienna a p p r o a c h c o n t r o l . The pilot w a s
advised to use the h o m e r f o r a p p r o a c h and a
QDM of 100" w a s given a t 1429 h o u r s . A t 1430
the a i r c r a f t r e p o r t e d o v e r r a d i o beacon OEW
and w a s i n s t r u c t e d t o r e m a i n 150 m e t r e s
(500 feet) above the cloud top. A QDM of 123"
w a s obtained a t t h i s t i m e . A t 1431 the a i r c r a f t
w a s c l e a r e d t o descend t o 1 060 m e t r e s (3 500
f e e t ) and i n s t r u c t e d t o r e p o r t again a t this a l t i -
tude o v e r beacon OEW. The flight w a s c l e a r e d
then f o r a n i n s t r u m e n t a p p r o a c h , the pilot was
given the QNH setting f o r h i s a l t i m e t e r and in-
s t r u c t e d t o u s e Runway 12. B e a r i n g s w e r e
t a k e n and QDM1s r e p o r t e d t o the pilot, the l a s t
being: "1439 h o u r s : QDM 140". A s r e q u e s t e d ,
t h i s one w a s r e p e a t e d . However, i t was not
acknowledg-d by the pilot. S h o r t l y a f t e r , the
a i r c r a f t , while flying In the d i r e c t i o n of the
a i r p o r t , with landing g e a r down and f l a p s a t the
a p p r o a c h a n g l e , gave full throttle f o r a m o m e n t ,
pulled up and c r a s h e d a t 1440 h o u r s into the
northwest slope of the Kahlenberg, facing up-
hill. F i r e b r o k e out following i m p a c t and t h e
a i r c r a f t w a s completely d e s t r o y e d . The pilot
a n d five p a s s e n g e r s w e r e killed and one pas-
s e n g e r received f a t a l i n j u r i e s . T h e o t h e r
occupants of the a i r c r a f t received i n j u r i e s of
varying d e g r e e s and seven p a s s e n g e r s r e q u i r e d
n o m e d i c a l attention whatsoever.
Investigation and Evidence
A m a s s of w a r m a i r moving i n f r o m the
s o u t h e a s t on the t a i l of a cold f r o n t w a s causing
precipitation throughout the Vienna a i r p o r t a r e a ,
with visibility of 1 - 1 . 5 k m and 0 . 5 - 1 k m i n
t h e Vienna c i t y a r e a . The a v e r a g e height of
the b a s e of the m a s s i v e cloud bank w a s 300
m e t r e s above s e a l e v e l , while the upper l i m i t ,
o n the b a s i s of the Vienna radiosonde o b s e r v a -
t i o n a t 1500 h o u r s Greenwich Mean T i m e , m u s t
have been 3 300 m e t r e s .
c a s t s f o r the Vienna a i r p o r t a r e a w e r e
i s s u e d by the a i r p o r t m e t e o r o l o g i c a l station
and t r a n s m i t t e d by r a d i o t o the c r e w s of
approaching a i r c r a f t .
1430 GMT 270/02 Kt, 1 . 4 , m i s t , 5/8 F s
120 m , 8/8 S t 240 m ,
QNH 1 0 2 4 . 7 , Q F E 1003.3
1500 GMT 270/02 Kt, 1. 3 k m , d r i z z l e ,
5/8 F s 90 m, 8/8 S t 150 m ,
QNH 1024.7, Q F E 1003.3
1300 GMT f o r 14-2000 GMT v a r / 0 2 K t ,
1 . 2 k m , r a i n , 7/8 St 300 Ft
p r o b . 20 t e m p o 2 k m , m i s t ,
2/8 S t 600 F t . 8/8 S t 1000 F t
1400 GMT f o r 15-2100 GMT var/02 Kt,
1 . 2 k m , r a i n , 7/8 S t 300 F t
prob. 30 t e m p o 2 k m , m i s t , 2/8 S t
600 F t 8/8 S t 1000 Ft
T h e following a i d s w e r e available a t Wien-
Schwechat a e r o d r o m e and functioning n o r m a l -
ly a t the t i m e of t h e accident: Non-direction-
a1 beacon (NDB) OEW, 408 k c / s - 1 . 2 KW;
non-directional locator beacon (L) WO, 378
k c / s - 40 W, combined with a 75 MC/S m a r k -
e r beacon, and a non-directional l o c a t o r
beacon ( L ) WN, 3 2 5 . 3 k c / s - 40 W . NDB
OEW which s e r v e s a s a h o m e r , i s located a t
the w e s t e r n edge of t h e a i r p o r t , while b e a c o n s
W O and WN a r e t o the w e s t and e a s t of t h e
field on t h e extended c e n t r e line of the runway.
A VHF D/F i s provided t o the south of the e a s t
runway. During t h e a p p r o a c h , both the high
intensity a p p r o a c h lights a n d the high i n t e n s i t y
runway lights w e r e t u r n e d on t o full intensity.
The a p p r o a c h light s y s t e m c o n s i s t e d of 102
lighbs, e a c h of which provided 20 000 candle-
power a t full intensity. At the t i m e of t h e
incident, the a i r c r a f t w a s in contact with the
c o n t r o l t o w e r and the VHF D/F o n 1 1 9 . 7 MC/S.
192 ICAO C i r c u l a r
I t was not p o s s ~ b l eto a s c e r t a ~ n ,e i t h e r
f r o m the wreckage o r f r o m the t e s t i m o n y of
the w i t n e s s e s , whether the a i r c r a f t f i r e extin-
guishing s y s t e m had been operated. I t c a n be
a s s u m e d t h a t i t was not since i m m e d i a t e l y
following the c r a s h the c r e w w e r e incapable of
t a k ~ n ga n y actlon t o p r e v e n t f i r e and the a i r -
c r a f t began t o b u r n when the explosions o c c u r r e d .
T h e a i r c r a f t c r a s h e d a t a point 390 m e t r e s
above s e a level, 200 m e t r e s w e s t of the i n t e r -
section of the Leopoldsberg-Kahlenberg and
Leopoldsberg-Klosterneuberg r o a d s . P a r t s of
the landing g e a r w e r e s c a t t e r e d just b e f o r e the
point of i m p a c t , together with the left a i l e r o n
and p a r t s of the left wing f l a p s which w e r e t o r n
off by the tops of the t r e e s growing on the s t e e p
h ~ l l s i d e . The fuselage and the r e m a i n d e r of the
wing l a y facing uphill a t the edge of the road-
way, and a t rlght a n g l e s t h e r e t o . The right
leg of the landing g e a r , which w a s down, w a s
t o r n off by contact with the roadway and the
c u r b m a r k i n g s t o n e s and w a s found lying on the
roadway.
The f o r w a r d section of the fuselage and
the cockpit w e r e s e v e r e l y c r u s h e d and the p a s -
s e n g e r cabin s e c t i o n w a s t o r n off. A l l equip-
m e n t and fittings of the a i r c r a f t w e r e displaced
b y the i m p a c t . F u r t h e r m o r e , the f i r e , which
broke out i m m e d i a t e l y following the i m p a c t
completely d e s t r o y e d a l l the equipment and the
m a i n components of the a i r c r a f t , with the ex-
ception of those which w e r e t o r n off and l a y
a p a r t . Consequently, no r e l i a b l e information
which could be of u s e in the investigation could
be obtained f r o m the a i r c r a f t equipment o r
~ n s t r u m e n t s . I m m e d i a t e l y following the c r a s h
and before the f i r e had been extinguished, the
injured passengers were forcibly extricated
f r o m the wreckage. Removal of the v i c t i m s
a l s o r e q u i r e d d i s p l a c e m e n t of the wreckage.
I n addition, t h e f i r e fighting ope r a t i o n s c a u s e d
c o n s i d e r a b l e d i s p l a c e m e n t of the wreckage be-
f o r e the a r r i v a l of the i n v e s t i g a t o r s . I t w a s ,
t h e r e f o r e , i m p o s s i b l e t o a s c e r t a i n with a n y
a c c u r a c y the m a n n e r i n which t h e c r a s h o c c u r -
r e d , f r o m the position i n which t h e investiga-
t o r s found the wreckage.
According t o information provided by the
a i r l i n e , t h e i r pilots a r e i n s t r u c t e d , in the
event of IFR conditions a t Schwechat a e r o -
d r o m e , t o proceed a s follows when i n s t r u c t e d
b y a e r o d r o m e control t o a p p r o a c h on a 120"
heading:
a) Reduce altitude t o 3 500 f e e t by c i r -
cling between beacons OEW and W N ;
b) A f t e r descending t o 3 500 f e e t
and on r e c e i p t of c l e a r a n c e f r o m
a i r t r a f f i c c o n t r o l , f l y on a 320"
heading f o r two and a half m i -
n u t e s , descending t o 2 500 feet;
c) On reaching 2 500 f e e t on 320"
m a g n e t i c , execute a p r o c e d u r e
t u r n t o the left until on 120"
magnetic ;
d) When on 120" m a g n e t i c , d e s c e n d
gradually t o r e a c h a n altitude of
e x a c t l y 1 800 f e e t o v e r beacon
wo;
e) F r o m beacon WO, d e s c e n d g r a d -
ually on a 120" heading t o 1 000
feet;
f) If visual contact i s not m a d e f r o m
t h i s altitude, c l i m b in the s a m e
d i r e c t i o n t o 1 600 f e e t and a w a i t
further instructions f r o m a i r
traffic control.
F r o m the s t a t e m e n t s m a d e b y the a i r
t r a f f i c c o n t r o l l e r and by the pilot of a n o t h e r
J A T a i r c r a f t which w a s flying in t h e vicinity
a t the t i m e , i t i s a s s u m e d t h a t the pilot-in-
c o m m a n d of YU-ADC was a l r e a d y a w a r e of
t h e unfavourable weather conditions prevail-
ing a t Schwechat when he approached t h e a i r -
port.
F r o m the evidence given by the a i r
t r a f f i c c o n t r o l l e r i t i s a s s u m e d t h a t the a i r -
c r a f t r e p o r t e d a s i n s t r u c t e d o v e r beacon OEW.
F r o m the b e a r i n g s taken a t 1429 and 1430
h o u r s , h o w e v e r , i t i s a p p a r e n t t h a t the a i r -
c r a f t could not have been exactly o v e r beacon
OEW
It w a s f u r t h e r confirmed b y the s t a t e -
m e n t s of the o t h e r c r e w m e m b e r s t h a t the
pilot-in-command showed that he intended t o
land by switching on the "No Smoking-Fasten
S e a t Belts" sign. It i s a l s o a s s u m e d f r o m the
s t a t e m e n t m a d e by the a i r t r a f f i c c o n t r o l l e r
t h a t t h e flight on the outbound t r a c k until c o m -
m e n c e m e n t of the p r o c e d u r e t u r n l a s t e d s e v e n
m i n u t e s ( f r o m 1431 t o 1438 h o u r s a s confirm-
e d by the direction-finding log) and t h e r e f o r e
exceeded by f o u r and a half m i n u t e s the
d u r a t i o n p r e s c r i b e d by JAT f o r the IFR p r o -
c e d u r e . Nor did the a i r c r a f t maintain t h e
a l t i t u d e s p r e s c r i b e d in the a i r l i n e ' s landing
p r o c e d u r e f o r unfavourable weather conditions
 ICAO Circular 5 0 - A ~ / 4 5
since i t did not hold the 3 500 foot ( 1 060
m e t r e ) altitude prescribed f o r the outbound
t r a c k and the procedure turn but descended to
1 280 feet (190 m e t r e s - height of the point
where the accident occurred) and was therefore
considerably below the prescribed altitude of
1 800 feet even before reaching beacon WO.
The statements made by the co-pilot and
that made by one of the passengers indicate
that the pilot must have assumed, shortly be-
f o r e the c r a s h , that he was on final approach
since he had lowered the landing gear and
extended the flaps. F r o m the statements of the
co-pilot and the testimony of two witnesses i t
m u s t a l s o be concluded that the engines were
throttled down f o r final approach shortly before
the c r a s h .
ICAO Ref: A ~ / 4 1 3
193
Probable Cause
The accident was caused by the fact that
the a i r c r a f t flew f o r a longer period on the out-
bound t r a c k and descended below the prescribed
minimum altitude laid down a t the time by the
airline f o r operations into Schwechat aerodrome.
Recommendation
It is recommended that any airline which
p r e s c r i b e s particular landing procedures o r
meteorological minima f o r operation of i t s a i r -
c r a f t into a given aerodrome should communi-
cate these procedures and minima to the a i r
traffic control authorities of that aerodrome to
permit the latter to supervise approaches made
by such a i r c r a f t and to enable them t o intervene
with a warning in case of emergency.
 194 ICAO Circular 5 0 - A ~ / 4 5

No. 46

Beech Bonanza, C-35, crashed into an apartment building in North Hollywood, California,
on 17 October 1955. Civil Aeronautics Board (USA)
Accident Investigation Report No. SA-313, F i l e No. 2-0050,
released 9 March 1956.

Circumstances F r o m the information provided by wit-

The pilot filed a Defence Visual Flight
Rules flight plan f r o m the Lockheed Air Termi-
nal, Burbank, California to McCarran Field,
Las Vegas, Nevada. He estimated his departure
time a s 2115 hours Pacific Standard Time and
indicated that the a i r c r a f t had sufficient fuel f o r
four hours of flight. At 2159 the pilot requested
taxi and take-off instructions, was cleared to
Runway 15 (150 degrees magnetic), and was
given the latest wind and altimeter information.
He was asked whether he was IFR (Instrument
Flight Rules) o r just a climb to on top and repli-
ed that he wanted a clearance to climb westbound
to on top. At 2208 the flight was cleared a s
follows : "Bonanza 25C taxi into position and
hold. Your climb out a f t e r take-off, make right
turn, climb on magnetic heading of 260 d e g r e e s
to on top, report on top. ' I The take-off appeared
normal to the tower personnel and it was noted
that the navigation and two anticollision lights
(Crimes lights) on the a i r c r a f t were on through-
out this time. The a i r c r a f t was l a s t seen f r o m
the tower turning right and climbing toward the
overcast. There were no other radio contacts
with the flight. Shortly thereafter calls were
received by the Burbank controllers f r o m r e s i -
dents south and southwest of the a i r p o r t report-
ing an a i r c r a f t in that a r e a flying v e r y low and
. appearing to be in trouble o r stunting. At 2214
the a i r c r a f t crashed into an apartment building
4. 3 miles southwest of the a i r p o r t , fatally injur-
ing the pilot and eight residents of the building.
One other resident was seriously injured, the
building received major damage and the a i r c r a f t
was destroyed by impact and the f i r e which
followed.
Investigation and Evidence
The weather a t the time of the accident
was a s follows: ceiling 700 feet overcast; visi-
bility 2 miles, smoke and haze; top of the over-
cast reported variable 2 500 to 3 000 feet mean
s e a level o r 1 800 to 2 300 above the ground. The Next to s e e the a i r c r a f t were s e v e r a l
pilot had been advised of these conditions. witnesses located more than one mile southwest
n e s s e s the probable flight path of the a i r c r a f t
was reconstructed and i s shown a t F i g u r e 25.
Witness No. 1, an a i r c r a f t mechanic,
saw N 25C immediately after take-off a s it turn-
ed right to a 260 degree heading and climbed
into the overcast. Shortly thereafter he heard
the engine sound get louder and in a manner
which gave him the impression that the a i r c r a f t
was turning left and descending rapidly. The
Bonanza was then seen to emerge f r o m the
overcast a t very high speed, diving steeply and
turning left. The nose of the a i r c r a f t jerked up
sharply while the turn continued through north
to a west heading, completing one 360 degree
turn f r o m the f i r s t observed direction. The
a i r c r a f t again disappeared into the overcast,
climbing steeply. This witness stated positive-
ly that the anticollision lights were on while he
could s e e the aircraft.
The second witness, a pilot, was located
west of the f i r s t . He stated that N25C was
observed to pass closely over his position three
times while it flew a c i r c u l a r path, approximate-
ly one-half mile in diameter. During this time
he observed the a i r c r a f t climb into and dive out
of the overcast s e v e r a l times. He stated these
e r r a t i c movements seemed to indicate the pilot
was having difficulty with l a t e r a l and longitudi-
nal control. He thought the engine sound increas-
ed and decreased with vertical oscillations of
the a i r c r a f t . The engine sounded a s though i t
were operating with an appreciably high power
setting and with i t s propeller in fairly low pitch.
The engine sound, however, was uninterrupted
and did not indicate any malfunction. He observ-
ed that the navigation lights were on but said
the anticollision lights were off. No witnesses
a f t e r the f i r s t observed the l a t t e r lights to be
on. When the a i r c r a f t passed the witness the
third time it assumed a westerly heading and
again climbed into the overcakt.
 ICAO Circular 5 0 - ~ ~ / 4 5
of the f i r s t two, and slightly l e s s than one mile
north-northeast of the accident site. One of
these witnesses, with dive bomber experience,
said the sound was unmistakably that of an a i r -
craft diving and pulling up. In this a r e a the
Bonanza again flew a t least one complete 360-
degree c i r c u l a r path.
Witnesses in the immediate accident a r e a
who saw the c r a s h stated that just prior to the
accident the a i r c r a f t dived out of the overcast a t
an estimated 65-75-degree angle on a southeast
heading but turning rapidly to i t s right. It pulled
up sharply when it reached a southwest heading
a t which time s e v e r a l large components separat-
ed f r o m the main a i r c r a f t s t r u c t u r e . Rolling
violently to the right the major structure plunged
into the apartment roof. An explosion and in-
tense fuel f i r e followed.
The a i r c r a f t structure available f o r exam-
ination was greatly limited. Major portions of
the right wing, right flap and aileron together
with the empennage were found a t varying dis-
tances up to s e v e r a l hundred yards northeast of
the main wreckage site. This was confirmation
that the a i r c r a f t had sustained an inflight failure
of its basic structure.
The p r i m a r y failure of the right wing
occurred just outboard of the wing-to-centre
section attachment in upward o r positive bending
a s a result of loads in excess of the strength of
the structure. Chord-wise compression buckles
were evident on the upper wing surface outboard
of the p r i m a r y f r a c t u r e s . In addition, numerous
diagonal wrinkles were found on both the upper
and lower surfaces of this wing. The type and
direction indicated they were produced by a high
nose-down torsional load on the wing box struc-
ture.
The right aileron and a major portion of
the right flap separated in flight. Evidence
clearly showed they were torn f r o m the wing by
f o r c e s in excess of their strength. The twin
inboard flap hinge ribs had been torn f r o m the
flap but remained in place in the wing. These
were found jammed in the flap's retracted posi-
tion. This flap position was further verified by
comparing the flap drive s c r e w extension of
N 25C with that of another Bonanza with flaps
retracted. The rlght aileron failed and separated
195
In three sections. Evidence showed that
before separation the aileron had been positioned
well past its normal down travel.
The left and right tail sections showed no
evidence of f i r e o r that they had been struck by
any other component of the a i r c r a f t . The prirna-
r y inflight failures of both occurred a t the s p a r -
to-fuselage attachment. Both failures were
similar except the right section failed upward
under positive loads while the left failed down-
ward under negative force. These f a i l u r e s
indicated violent right rotation of the a i r c r a f t
along its longitudinal axis following the right
wing separation.
Evidence showed that the landing gear
was retracted a t the time of the accident.
Numerous metal samples f r o m the avail-
able s t r u c t u r e were examined by metallurgists
under laboratory conditions. Results disclosed
that the material was within the specification
limits and t h e r e was no evidence of fatigue
failure.
Since an inflight s t r u c t u r a l failure of the
a i r f r a m e had occurred in this accident a review
of the design data was made by Board investi-
gators. This review showed that the s t r u c t u r a l
design met and in many instances exceeded the
minimum strength requirements of P a r t 3 of
the Civil Air Regulations. It a l s o showed the
adequacy of the design was thoroughly verified
by extensive laboratory testing. Because the
wing failure of N 25C appeared to have resulted
f r o m a rolling pullout type of loading, the Board
requested the a i r f r a m e manufacturer t o provide
data of the a i r f r a m e strength for this manoeuvre.
The manufacturer's r e p o r t , submitted a s an
exhibit at the public hearing, indicates that the
wing design incorporated strength f o r a n ulti-
mate load factor of f r o m 5.25 to 5.80 g l s , a s
compared with required minimum strength of
4.4 g ' s .
There was no evidence found to indicate
malfunction o r failure of the a i r c r a f t s t r u c t u r e
o r controls prior to the load-induced failure.
At the time of the accident the Civil
Aeronautics Administration was in the process
of filing a violation report against the pilot f o r
196 ICAO C i r c u l a r 5 0 - ~ N / 4 5
M

flying without an instrument rating under condi-
tions and c i r c u m s t a n c e s requiring one? The
f l r s t incident on which the violation was b a s e d
o c c u r r e d on 10 October 1955 when the pilot was
flying N 25C f r o m F u l l e r t o n A i r p o r t , Fullerton,
California, to the Orange County A i r p o r t , Cali-
fornia. During the flight he climbed without a
c l e a r a n c e through the o v e r c a s t and upon reaching
the Long Beach a r e a , and s t i l l flying above the
o v e r c a s t , decided t o land a t the Long Beach
A i r p o r t . M e was given a n i n s t r u m e n t procedure
c l e a r a n c e to descend, however, then exhibited
e x t r e m e difficulty in understanding it. The m g
Beach c o n t r o l l e r explained the procedure to h i m
in exacting detail but he s t i l l showed e x t r e m e
difficulty i n c a r r y i n g i t out. Because of t h i s ,
traffic in the a r e a was delayed 45 minutes.
While the 10 October incident was under
f u r t h e r investigation a second s e r i e s of com-
plaints against the pilot was submitted to the
CAA. It was l e a r n e d that on 7 and 8 October
he took off f r o m the Fullerton A i r p o r t without
c l e a r a n c e when the visibility was one mile o r
l e s s and climbed through a n o v e r c a s t t o above
the clouds. This information was obtained while
F u l l e r t o n officials w e r e investigating the s o u r c e
of s e v e r a l e x t r e m e l y low flights (buzzing) over
the city by a n a i r c r a f t without lights. Investiga-
tion r e v e a l e d that these incidents o c c u r r e d when
only this pilot had taken off f r o m the a i r p o r t .
An official of the a i r p o r t testified that the pilot
had previously been reprimanded f o r unreasons-
bly f a s t taxiing and a s a r e s u l t of the ltbuzzingfl
had been requested to b a s e his a i r c r a f t e l s e -
where. It was while moving his a i r c r a f t to
Orange County that the 10 October incident took
place.
O n 11 October the pilot voluntarily c a m e
to the CAA offices a t Long Beach and readily
admitted the incidents. ~t this tirne he stated
that he held no i n s t r u m e n t rating but showed
he was f a m i l i a r with the regulations applicable
to the aforementioned flights. He was advised
a t this t i m e to t e r m i n a t e s u c h i n s t r u m e n t flights
until he demonstrated capability and was certif-
icated f o r them.
The pilot had purchased N 25C on 10 June
1955. The a i r c r a f t was fully equipped a t this
t i m e with instrumentation and appliances f o r
instrument flight and nlght flying. It had b e e n
completely Inspected a t the time of s a l e and
was considered t o be in n e a r perfect condition.
When purchasing N 25C the pilot was
given a demonstration flight and was advised to
take instruction before operating the a i r c r a f t .
He flew with an i n s t r u c t o r f o r about two h o u r s
and during tlils time insisted that the instruction
be conflned to take-off and landing practice.
After the flight the i n s t r u c t o r told the pilot that
he was not considered checked out; however,
the pilot stated that he could f l y the a i r c r a f t and
took no f u r t h e r instruction. The i n s t r u c t o r
testified during the public h e a r i n g that the pilot's
flying was Itvery rustyl1 and showed little evi-
dence that he had actually accumulated 3 000
h o u r s o r that 800 hours w e r e instrument which
he had claimed.
Other witnesses s t a t e d that the pilot was
f a m i l i a r with the a l r c r a f t instrumentation, knew
how to use i t and that he s e e m e d c a r e f u l and
conservative while flylng. One witness s a i d
that she had been wlth h i m when he climbed
through the o v e r c a s t on s e v e r a l occasions and
he did not use the a i r c r a f t l s auto-pilot. He was
in the habit of climbing and descending while
controlling the a l r c r a f t manually. She added,

\+ "60.12 C a r e l e s s o r r e c k l e s s operation. No person s h a l l o p e r a t e a n a i r c r a f t in a c a r e l e s s

o r r e c k l e s s manner s o a s to endanger the life o r property of o t h e r s .

1'60.31 Visibility

b) Flight visibility within control zones. When the flight visibility is l e s s than 3
miles, no person shall o p e r a t e a n a i r c r a f t in flight within a control zone, unless
a n a i r traffic c l e a r a n c e i s obtained f r o m a i r traffic control;

c ) Flight visibility within control a r e a s . Whcri the flight visibility i s l e s s than 3

m i l e s , no person s h a l l o p e r a t e a n a i r c r a f t within a control a r e a ;

NOTE: When the flight visibility i s l e s s than 3 m i l e s , operations within control

a r e a s a r e to be conducted In accordance with instrument flight r u l e s .
Flight below 700 f e e t above the s u r f a c e 1s not within a control area."

"43.65 Instrument flight limitations. A pilot shclll not pllot a i r c r a f t under instrument
flight r u l e s , unless he holds a valid instrurnrnt rating issued by the Administrator,"
 ICAO C i r c u l a r 50-AN/45
however, that he did use the auto-pilot uurlng e n
route flight and was fully acquainted wlth ~ t use
s tion work was p e r f o r m e d l t was determined that
and operation.
During the investigation it was l e a r n e d
that a 52-gallon aonstandard a u x i l i a r y fuel tank
was installed in the a i r c r a f t baggage c o m p a r t -
ment. The modification work and n e c e s s a r y
weight and balance computation w e r e complete
and the data was submitted t o the CAA f o r a p p r w -
a l . The ACA-337 ( ~ a j o R r e p a i r and Alteration
Report) f o r m accompanying this data was dated
6 October 1955. F i n a l approval f o r t h i s installa-
tion had not been given and the a i r c r a f t should
not have been o p e r a t e d pending s u c h approval.
The pilot, however, continued t o fly i t c o n t r a r y
to Civil A i r Regulations governing such alteration.
The day of the accident the pilot d e p a r t e d
Lockheed A i r T e r m i n a l a t 0444 h o u r s intending
to f l y to L a s Vegas. At 0452 he r e t u r n e d to the
a i r p o r t , landed, and then called the CAA com-
municator and canceled h i s flight plan comment-
ing that he r e t u r n e d b e c a u s e the navigation lights,
G r i m e s lights and r a d i o had failed in flight. He
f u r t h e r s t a t e d that the G r i m e s lights had b e e n
i n s t a l l e d on 15 October and he suspected an e l e c -
t r i c a l p r o b l e m f r o m the installation which i n c o r -
porated the lights that failed in a c o m m o n circuit.
During the day the pilot told Pacific A i r -
motive Corporation employees that he was dlssat-
isfied with the installation and wanted the G r i m e s
lights repositioned f a r t h e r f o r w a r d on h i s a i r -
c r a f t . He i n s i s t e d that one b e mounted above and
just behind the pilot s e a t on the top of t h e fuselage.
The o t h e r was installed on the bottom of the a i r -
c r a f t slightly f a r t h e r r e a r w a r d than the top light.
With the one on top mounted upward and the o t h e r
inverted the r e s u l t a n t rotatlng f l a s h e s moved in
opposite d i r e c t i o n s . Both lights w e r e controlled
by s e p a r a t e switches and could be turned off o r
on independently of e a c h o t h e r and any o t h e r lights
on the a i r c r a f t . The lights w e r e functionally
t e s t e d and o p e r a t e d n o r m a l l y . Employees of the
r e p a i r agency s t a t e d that b e c a u s e the a i r c r a f t logs
w e r e not in the a i r c r a f t a new computation of the
a i r c r a f t c e n t r e of g r a v i t y was not. made nor was
a Major Repair and Alteration Report, f o r m 337,
completed. Also, no e l e c t r i c a l a n a l y s i s w a s made
following the light installation and no flight t e s t
was p e r f o r m e d t o d e t e r m i n e how the lights func-
tioned i n flight o r if any reflection o r g l a r e
See h l l g n ~u l f e t y Foundation Bulletin r e F l i c k e r Vertieo in P a r t I11 of t h i s Digest.
** As a r e s u l t of t h e B o a r d ' s investigation of this accident the A i r c r a f t Owners and P i l o t s
Association and the Beech A i r c r a f t Corporation i s s u e d bulletins t o pilots d e s c r i b i n g the
e f f e c t s of f l i c k e r v e r t i g o f r o m using t h e s e lights in an o v e r c a s t . Beech a d v i s e s "turn off
your r o t a r y beacons b e f o r e entering an o v e r c a s t .
197
r e s u l t e d dur tng their operation. While the r e l o c a -
the p r i o r f d l l u r e of the navigation and G r i m e s
llghts had o c c u r r e d b e c a u s e a n Inadequate c i r -
cult b r e a k e r was Installed dorlng the o r i g i n a l
installation on that c i r c u i t . The r a d l o trouble
was r e p a i r e d by replacing a burned-out tube.
Durlng the accident investigation flight
t e s t s w e r e conducted to d e t e r m i n e what, if any,
effect the G r i m e s rotating lights had on a pilot
whlle flying in the o v e r c a s t . T h e s e t e s t s w e r e
c o n s i d e r e d especially i m p o r t a n t b e c a u s e the
pllot apparently l o s t control of h i s a i r c r a f t
while flylng in the o v e r c a s t . Using a Beech
Bonanza, with n e a r l y ldentlcally mounted lights,
the t e s t s w e r e flown by a qualified i n s t r u m e n t
pilot and o b s e r v e d by a B o a r d investigator.
The suspicions of the a c c i d e ~ l ti n v e s t i g a t o r s
w e r e b o r n e out during t h e s e t e s t s and i t was
l e a r n e d that an Immediate and s e r i o u s l y d i s -
tracting effect was caused by the lights. It w a s
l e a r n e d that the opposite rotation and b r i l l i a n c e
of the f o r w a r d mounted lights c a u s e d the clouds
to a p p e a r to move in, out, up, and down when
the f l a s h e s s t r u c k tfie a i r c r a f t wings and p r o -
p e l l e r , reflecting into and around the cockpit.
The pilot was i m m e d i a t e l y confronted wlth
s e r i o u s vertigo'k which r e q u i r e d the highest
d e g r e e of s k i l l and concentration t o maintain
i n s t r u m e n t c o n t r o l of the a i r c r a f t while being
affected by the distracting condltlons. F r o m
the t e s t s it was concluded that lights ~ n s t ~ l l l e d
and operating in this m a n n e r could c a u s e d i s -
t r a c t i o n and vertlgo of a d i s a s t r o u s effect on
pilots with limited experience?'?
Idany p e r s o n s s a i d that the pilot a p p e a r e d
t ~ r e dthroughout the day and evenlrlg b e f o r e the
flight whlch r e s u l t e d in the accident.
Officials f r o m the CAA Office in the region
w h e r e the accident o c c u r r e d testlficd durlng
the public h e a r i n g a n d e x p r e s s e d d i s s a t i s f a c t i o n
with the Clvil A i r Regulations governing f l i g h t s
within a c o n t r o l zone. They pointed out t h e r e
was no c l e a r dellneation in the r u l e s that d i s -
tinguished IFR and VFR flight conditions. They
s t a t e d t h c r e is misunderstanding r e g a r d i n g t h e
n a t u r e of a t r a f f i c c l e d r a n c e wherein s o m e pilots
believe that a c l e a r a n c e to "take off f r o m " o r
"enter" n c o n t r o l zone automatically r e l e a s e s
the pilot f r o m a d h e r e n c e to pertinent regulations
198 ICAO Circular 5 0 - ~ ~ / 4 5 -
relating to pilot qualification o r certification. appropriate flight instruments. This opinion i s
Many pilots further believed such clearance on supported b y the general problems of instrument
a V F R flight plan a l s o permitted a clirnb through flight and by other accidents o r near accidents
an overcast o r other flight when control of the which occurred in the s a m e manner f o r this
a i r c r a f t was possible only by reference to flight reason. It i s believed that following the initial
instruments. The witnesses emphasized that s p i r a l the pilot was unable to recover full c o n t r d
among highly qualified aviation personnel the of the a i r c r a f t and continued to reenter and dive
intent of the existing regulations to prohibit such out of the overcast. He was apparently flying
abuse was understandable; however, f o r enforce- alternately under visual conditions, immediately
ment purposes, a responsibility of the CAA, the thereafter confronted by instrument conditions,
rules were ambiguous and lacked sufficient spec- and was never able to regain complete control
ificity to provide that intent with adequate en- of the a i r c r a f t . During this time he flew s e v e r a l
forceability.* c i r c u l a r patterns, obviously influenced by des-
pe ration and panic and possibly attempting to
Following the accident, in the interest of r e t u r n to the a i r p o r t o r avoid high t e r r a i n on a l l
corrective action, g r e a t e r supervision, and safe- sides except the west. It appears that he then
ty, CAA operations personnel of the region re- tried to climb through the o v e r c a s t again but
quire a pilot filing a flight plan to indicate wheth- before reaching the c l e a r a r e a above i t enter-
e r o r not he holds an instrument rating. This ed another steep descending spiral. An abrupt
information will be furnished the tower control- turning pull-up f r o m this s p i r a l caused s t r u c -
l e r s interested in the flight and if conditions of t u r a l failure.
weather a r e l e s s than 1 000 feet ceiling and/or
l e s s than one mile visibility the pilot on a VFR The investigation established that the
clearance will be advised to postpone the flight design limitations of N 25C had been exceeded
o r file the flight plan according to instrument in the abrupt pull-up following the final dive,
rules. F u r t h e r , a i r c r a f t arriving in the control and that no mitigating s t r u c t u r a l design defi-
zone under a VFR flight plan i n the stated condi- ciencies were involved in the failures. While
tions will be reported to enforcement officials the excessive loads were undoubtedly imposed
for investigation. inadvertently o r a s a final desperate move to
a r r e s t the dive, this fact cannot be considered
As indicated the a i r c r a f t was observed to a s a reflection on the a i r c r a f t design. While
take off in a normal manner and to begin a right such factors a s cleanness of design, compara-
climbing turn in apparent conformity to the de- tively light stick f o r c e s , turbulent a i r , etc. ,
parture clearance. Thereafter it established undoubtedly do contribute to the e a s e with which
the climb out heading and disappeared f r o m view control i s lost there i s no substitute for proper
in the overcast. Several qualified witnesses instrument training and proficiency f o r a safe
stated that during this time the engine seemed to and sound operation of a i r c r a f t in overcast
be operating normally and the a i r c r a f t was fully weather conditions.
lighted, including the rotating beacons. Shortly
thereafter, however, the engine and propeller The Board i s of the opinion that the initial
sound increased in a manner which indicated to vertigo was the r e s u l t of s e v e r a l a d v e r s e f a c t o r s
the o b s e r v e r that the Bonanza was turning left personal in nature to the pilot and circumstantial
and descending rapidly. This was confirmed to the situation.
when N 25C suddenly emerged below the overcast
in a tight left spiral. This s e r i e s of events and The f i r s t of these factors i s believed to
the manner in which they occurred strongly in- have been his general d i s r e g a r d and d i s r e s p e c t
dicate that the pilot lost control of the a i r c r a f t f o r safe instrument flying practices and proce-
and a c h a r a c t e r i s t i c descending s p i r a l resulted, d u r e s . It appears that the pilot was quite willing
It i s a l s o believed that the l o s s of control proba- to climb through the overcast without clearance,
bly was induced by vertigo and the pilot followed proper certification, o r regard f o r other possible
his sensory indications in controlling the a i r - traffic. Although violation c h a r g e s were filed
c r a f t ' s attitude r a t h e r than indications f r o m the against him and he was recently reprimanded for

* As a r e s u l t of the extent of the misunderstanding that s e e m s to exist among pilots and the
position the CAA has taken with respect to the enforceability of the regulations, the Board
has initiated action looking toward the amendment of Sections 60.30, 60.31, and 43.65.

Such amendments would be designed to state specifically those minimum weather conditions
below which V F R flight could not be conducted within a ~oi111,olZ O l i r ' vven though a traffic
clearance were obtained.
 ICAO Circular 5 0 - ~ ~ / 4 5
these practices he again without the required
certification knowingly attempted to conduct anoth-
e r flight through the overcast. The fact that the
pilot did not hold an instrument rating does not
necessarily mean that he was incapable of instru-
ment flight; however, the Board feels that it may
indicate he was unsure of his ability and proficien-
cy to the extent that he was unwilling to attempt to
qualify for the rating.
The second factor i s considered circum-
stantial and i s believed to have been partially
responsible f o r the apparent vertigo. This factor
was the effect produced by the forward-mounted
rotating beacons, During flight t e s t s the opposite
rotating flashes and the attendant reflection were
capable of inducing serious and immediate vertigo
on a qualified instrument pilot. The Board i s
therefore of the opinion that it probably affected
the pilot in a like manner, Considering his fa-
tigued condition it i s believed he was even more
susceptible to vertigo, and it i s believed the fa-
tigue would also delay corrective action during
the initial loss of control and thereafter while
attempting to regain it.
The Board feels that there was little justi-
fication f o r the r e p a i r agency having installed a n
inadequate circuit breaker in the initial installa-
tion o r f o r having undertaken the installation o r
relocation of the lights without determining that
the pilot had the n e c e s s a r y a i r c r a f t records for
them to complete the work and properly return
the a i r c r a f t to service. Although maintenance
personnel were reluctant to relocate the lights
because of the suspected glare and reflection the
work was done despite this concern. Lacking the
ICAO R e f : ~ ~ / 4 1 9
199
n e c e s s a r y completion of the ACA-337 f o r m the
a i r c r a f t was being flown with an unapproved in-
stallation. F u r t h e r , because of the added elec-
t r i c a l load of the rotating beacons and the existing
electrical loads of the a i r c r a f t equipment, good
practice would have necessitated an electrical
analysis. Considering a l l factors, the pilot was
operating the a i r c r a f t contrary to Civil A i r Regu-
tions pertaining to such installations.
The Board has considered the possible use
of the auto-pilot during the departure and the pos-
sibility of i t failing a s a factor in the accident.
However, complete destruction of the components
n e c e s s a r y to determine this possibility precluded
the Board's ability to make such a determination.
Considering the testimony a s to the habit of the
pilot to control his a i r c r a f t manually during climb
out there i s no reason to believe he did not do it
this way on the subject flight. Also considering
that the attitude and directional gyros were vacu-
um driven the a i r c r a f t could have been manually
operated if the auto-pilot was not working provided
there was adequate cockpit lighting to s e e the
instruments. TPe continued operation of the
navigation lights throughout the flight indicates
that there was available electrical power for
cockpit lighting.
Probable Cause
The probable cause of this accident was
the pilot's l o s s of control during which the
design strength of the a i r c r a f t was exceeded
causing structural failure. Vertigo, and the
pilot's inability to take corrective action, were
contributing factors.
200 ICAO Circuhr 50-AN/ 45

l ' i ~ ~ ~25
re
PROBABLE FLIGHT PATH
OF BEECH B O N A N Z A N-5825C
N O R T H HOLLY WOOD, CALIFORNIA
OCTOBER 17, 1955

S C I L ~
0' 1000' am' Jmr' urn'

F l ~ g h tpath below overcast

Ir ------- Flight path In overcast
0 W~tness locotlons
@ Sne of occldent

Major streets only shown

o'ww&*
 ICAO Circular 5 0 - ~ ~ / 4 5
No. 47
United Air Lines, Inc., Douglas DC-6B, exploded in mid-air near Longmont,
Colorado, on 1 November 1955. Civil Aeronautics Board (USA)
Accident Investigation Report, File No. 1-0143 released 14 May 1956.
Circumstances
The flight departed L a Guardia Field,
New York, for Seattle, Washington, with sched-
uled stops a t Chicago, Illinois; Denver, Colorado;
and Portland, Oregon. On board were 39 pas-
sengers and a crew of 5. At Denver the r e a r
cargo pit (No. 4) was emptied and reloaded with
mail, freight and passenger luggage originating
a t Denver. The a i r c r a f t then received a rou-
tine ramp check, taxied to Runway 8R and was
cleared for the flight to Portland. The clear-
ance, in part, included compulsory radio reports
f r o m the flight upon passing the Denver Omni and
when climbing through 18 000 feet to i t s assigned
altitude, 21 000 feet. Following take-off the
flight reported its "off time" to the company a s
1852 hours Mountain Standard Time and reported
passing the Denver Omni a t 1856. This was the
l a s t communication f r o m the flight. At approx-
imately 1903 hours a mid-air explosion of disin-
tegrating force occurred aboard the a i r c r a f t and
i t crashed killing all 44 occupants.
Investigation and Evidence
The weather conditions for Denver were
a s follows:-
Ceiling measured 9 500 feet, overcast;
visibility 10 miles; temperature 36;
dewpoint 30; wind southwest 5 knots;
altimeter 29.84.
They indicated the flight, a s planned, would be
in accordance with instrument flight rules (IFR).
The wreckage of the a i r c r a f t was spread
along a north-northwest heading and covered an
a r e a of approximately six square miles, Within
this a r e a all the major components of the a i r -
craft were found. The tail group was located
about 4 600 feet south-southeast of two deep c r a -
t e r s which contained large portions of both
wings, the four powerplants, and main landing
gear. The forward fuselage was roughly 600
feet north of the c r a t e r s and the left outer wing
panel was found approximately 600 feet south of
the craters. This scatter of the heaviest and
largest pieces of wreckage showed that the
201
a i r c r a f t disintegration began in flight at an ap-
preciable altitude and that the separation of the
tail assembly occurred before separations of
the wings and forward fuselage.
The aft fuselage was found to have been
torn into a multitude of bits and pieces. Por-
tions of the structure were strewn over the
ground in a wide path extending south-southeast
approximately four miles from the main wing
wreckage, the l e s s dense fragments being at the
farther distances. P i e c e s of very low density
material, such a s paper and cabin insulation,
were found a s f a r a s nine miles south-southeast.
Many pieces of the aft fuselage comparable in
density to the tail group were found in the a r e a
adjacent thereto. This dispersal indicates that
the aft fuselage was shattered simultaneously
with the separation of the tail assembly and that
winds aloft-carried the l e s s dense pieces con-
siderable distance during their fall to the ground.
The severity of fragmentation indicates extreme-
ly violent shattering of this section of the a i r -
craft.
The forward fuselage f r o m the nose r e a r -
ward to a position approximately in line with
the wing spar came to r e s t where i t struck the
ground. Although severely flattened by impact,
the various pieces remained in their normal hor-
izontal relationship to one another. The complete
lower p a r t of this structure was in position a t
the bottom of the wreckage. The fuselage nose
cap bore no signs of impact; however, a small
box of electric motor equipment c a r r i e d a s
cargo and weighing 164 pounds, was imbedded
in the ground directly below a hole i t made upon
impact through the forward cargo compartment
floor. The importance of these observations
was that they showed the forward fuselage a s -
sembly struck the ground with g r e a t force in an
upright attitude while descending almost verti-
cally.
As previously stated major portions of
the wings and centre section were located in two
c r a t e r s , one of which was about 150 feet north
of the other. In the sou@ pit, which was about
20 feet wide, 25 feet long, and 6 feet deep, were
located the Nos. 1 a d 2 powerplants a s well a s
202 ICAO Circular 5 0 - ~ N / 4 5
a portion of the left wing. The north c r a t e r ,
somewhat longer and deeper than the other, con-
tained the Nos. 3 and 4 engines and portions of
the right wing. The depth of the c r a t e r s again
indicated the nearly vertical descent of the com-
ponents that made them. The distance between
c r a t e r s showed that both wing? separated f r o m
the fuselage prior to impact.
In addition to s e v e r e breakup of the struc-
t u r e , extensive f i r e damage occurred. This was
due to ignition of the fuel and oil which saturated
the ground in and around the c r a t e r s . Despite
efforts to extinguish the f i r e s , burning continued
for three days. The f i r e pattern in all c a s e s
clearly established that the f i r e s occurred fol-
lowing impact.
At an early phase of the investigation the
investigators became aware that an explosion
had occurred aboard this flight while a t an alti-
tude of s e v e r a l thousand feet above the ground.
It was also clear that the explosion was of such
great intensity that it would be unusual for i t to
have been caused by any system o r component of
the aircraft. This awareness was strengthened
by smudge m a r k s and odor characteristic of an
explosive that persisted on pieces of the frag-
mentized wreckage known to have been p a r t of
the fuselage structure in the a r e a of the No. 4
baggage compartment.
Because of the possibility of adverse
weather conditions and in o r d e r to reconstruct
the fuselage, the hundreds of pieces of wreckage
were transported to a warehouse where CAB in-
vestigators worked to rebuild the aft fuselage
structure in a mockup fashion by refitting each
fragment into i t s original position of construc-
tion. The mockup showed that the pieces were
progressively smaller f r o m a l l directions to-
ward a point in the No. 4 baggage compartment.
Many pieces were m e r e fragments o r were en-
tirely missing in that area. This reconstruction
and examination showed very conclusively that
the aft fuselage disintegrated from extremely
violent forces which originated in a very con-
centrated a r e a within the baggage compartment
below the aft buffet and just slightly left of the
centreline of the aircraft. The forces were
shown to have acted in all directions f r o m this
point. These blew the cabin floor upward, the
fuselage bottom shell outward, the aft bulkhead
of the baggage compartment rearward, and i t s
forward bulkhead forward. There i s nothing in
the structure of this p a r t of the a i r c r a f t that
could be the source of such an explosion.
NO evidence was found of fatigue cracking,
structural failure, o r malfunctioning controls
p r i o r to the explosion.
*
The four engines and propeller hubs were
found buried 6 to 10 feet in the two previously
mentioned c r a t e r s . All propeller blades were
also recovered f r o m these pits o r f r o m the im-
mediate a r e a s . The locations of these p a r t s in-
dicate that they remained attached to the two
main pieces of the wing until ground impact.
Examination of these badly damaged components
disclosed no evidence which would indicate that
any mechanical o r operational difficulty was ex-
perienced with them p r i o r to the s t a r t of disin-
tegration of the aircraft.
Numerous pieces of the a i r c r a f t and i t s
contents, bearing the sootlike smudges, were
subsequently examined in the FBI laboratory
to determine, if possible, what type of explosive
m a t e r i a l caused the destruction of the a i r c r a f t ,
The chemical analysis revealed that the residues
were those to be expected f r o m the explosion of
dynamite which contained sodium nitrate. The
analysis further disclosed that the residues on
many of the p a r t s contained manganese dioxide,
a major component of the mixture contained in
dry cell batteries. Eleven pieces of m a t e r i a l
which could have originated f r o m an Eveready
"Hot Shot" battery were found. These i t e m s a r e
two of the basic components of one type of a
bomb.
Descriptions of the explosion given by wit-
n e s s e s fully agreed with the physical evidence.
Several, who saw the a i r c r a f t before the explo-
sion, stated i t appeared to be climbing a t an e s -
timated altitude of 5 000 feet and the engines
sounded normal. This, they added, was sudden-
ly interrupted by a brilliant flash and followed by
a deafening explosion. The a i r c r a f t , in many
p a r t s , plunged to the ground where another ex-
plosion occurred. Flight t e s t s showed that the
altitude, course, and position of the flight when
the explosion took place were normal for a rou-
tine operation.
The evidence, and the analysis of the evi-
dence in this case, pointed to the possibility of
an explosion. In the f i r s t hours following the
accident Board investigators had uncovered
definite clues indicating that an explosive force,
probably f r o m within the a i r c r a f t but alien to i t ,
had torn the a i r c r a f t a p a r t in flight. Subsequent-
ly, by meticulously piecing together hundreds of
pieces of the torn and shatterad fuselage on a
chicken wire covered wooden f r a m e mockup of
the original DC-6B fuselage, Board investiga-
t o r s specifically determined that a dynamite-
type explosion had occurred within the No. 4
baggage compartment of the airplane. Conse-
quently, on 7 November, six days after the ac-
cident, the Board notified the Denver office of
the F e d e r a l Bureau of Investigation of its findings
 ICAO Circular 5 0 - ~ ~ / 4 5 20 3

so that the apparent criminal aspects involved that tne disintegration of the aft fuselage was
could be pursued immediately, a police function caused by an extremely violent explosion ema-
that i s outside the Board's jurisdiction. There- nating f r o m a very localized origin. The vio-
fore, on the following day, 8 November, the FBI lence was clearly shown by fragments which had
notified the Board's investigators that it would been projected through the cargo compartment
proceed with responsibility for the criminal por- walls and ceiling a s well a s by tearing, denting,
tion of the investigation. and curling of adjacent structure. This evidence
i s in sharp contrast to the damage of an explo-
As evidenced by the scatter of the a i r c r a f t sion resulting f r o m the ignition of any combusti-
wreckage and the practically vertical descent of bles c a r r i e d on and used during a i r c r a f t opera-
the individual pieces, i t i s obvious that the a i r - tion. Laboratory analysis confirmed this and
craft disintegrated a t an appreciable altitude. determined the explosive material was dynamite.
The relative locations of the pieces proved that
the f i r s t occurrence in the sequence of disinte-
gration was an extremely violent shattering of On 14 November 1955 agents of the F e d e r -
the aft fuselage with separation of the tail group. al Bureau of Investigation took into custody the
Without the tail the remaining a i r c r a f t structure son of one of the passengers. Thereafter, h e
probably pitched nose down a i d fell with uncon- was indicted for acts leading to the destruction
trolled gyrations during which the wing and for- of the a i r c r a f t by means of a bomb explosion.
ward fuselage separations occurred.

The reconstruction and examination of the Probable Cause

aft fuselage proved that the forces which caused
the initial disintegration radiated f r o m a point
within the number 4 cargo pit. The very pro-
nounced intensification in severity of fragmenta-
tion f r o m all directions toward this point proved
The probable cause of this accident was
the disintegrating force of a dynamite bomb ex-
plosion which occurred in the number 4 baggage
compartment.

ICAO Ref: ~ ~ / 4 2 5
 No. 48
Peninsular Air Transport, Douglas C-54-DC crashed at Seattle, Washington,
following take-off, 17 November 1955. Civil Aeronautics Board (USA
Accident Investigation Report SA-314, File No. 1-0145 released 3 May 1656.
Circumstances
The flight took off a t 2358 hours Pacific
Standard Time f r o m B ~ e i n gField, Seattle, for
Newark, New J e r s e y , carrying 78 persons, in-
cluding a crew of three and a third pilot, dead-
heading to Miami, Florida. The crew had r e -
ceived a n Instrument Flight Rules clearance
which instructed them, in part, to turn right
after take-off and climb on the northwest course
of ,the Seattle Range to 5 000 feet mean sea level.
The take-off appeared normal a s the landing
gear retracted and a right turn was begun.
When 300 - 400 feet above the ground the f i r s t
reduction of power was made and 5 of the 15
degrees of flaps extended were retracted. At
this time the No. 4 propeller surged and engine
r.p.m. increased to about 2 800. Unable to
reduce the r.p. m. of No. 4 by reducing i t s pow-
e r a n attempt was made to feather the propeller;
this also was unsuccessful. The a i r c r a f t then
began to descend and take-off power was reap-
plied to Nos. 1 , 2 and 3 engines and the power
f r o m No. 4 was further reduced. This action
did not reduce the r . p. m , of No, 4 which surged
again and increased to more than 3 000. The
a i r c r a f t veered to the right and continued to de-
scend. The captain realizing that a crash-
landing was imminent reduced the airspeed until
the a i r c r a f t was nearly stalled and applied full
power to all four engines. The a i r c r a f t con-
tinued to settle, struck a telephone pole. and
several t r e e s before crash-landing in a nose-
high attitude. Twenty eight persons were fatal-
ly injured, the major portion of the a i r c r a f t was
destroyed by impact and f i r e , and the accident
caused substantial property damage.
Investigation and Evidence
The a i r c r a f t crashed 2 1/2 miles f r o m
and 300 feet higher than the take-off position of
the flight. Examination of remaining portions
of the wings, fuselage and tail disclosed no evi-
dence of structural failure o r malfunction prior
to impact. No difficulty had been experienced
except for that associated with the No. 4 engine
and propeller.
Teardown inspections of Nos. 1, 2, and 3
engines and propellers disclosed no evidence to
indicate they were factors in the accident.
The No. 4 propeller, attached to the en-
gine nose section, was located about 25 feet
f r o m the main wreckage. There was oil cover-
ing i t s b a r r e l , the face side of all propeller
blades, and the engine nose section. Examina-
tion disclosed that the propeller dome retaining
nut protruded approximately one-eighth of an
inch above the b a r r e l dome bore and the safety
cap screw was p r e s s e d against the corner of i t s
safetying r e c e s s . The lock screw was safetied.
The screw was removed and i t s examination
showed no evidence of bending o r mutilation.
After the nut and b a r r e l were marked to show
their original positions a check was made for
tightness. The result showed the nut could be
moved with comparative ease with a s m a l l drift
and hammer for a t least 4 1/2 inches in the
tightening direction. The nut was then unscrew-
ed and the dome removed to check the propeller
blade pitch settings a s indicated by the cam gear
position. This revealed the cam gear lug was
against the low pitch stop, o r the normal low
pitch blade angle setting. The blade segment
g e a r s were marked to show their positions in
relationship to each other and to the cam gear.
The propeller assembly was then further disas-
sembled and examined after which i t was removed
f r o m the accident scene for continued examina-
tion and testing.
Examination was directed to ascertain the
individual blade angle settings. This disclosed
that all of the eight spring packs which retain
the segment gears, with their respective blades,
were mutilated and displaced such that this reten-
tion was destroyed. Each of the segment gears
was fractured at one of the spring pack r e c e s s e s .
This permitted f r e e rotation of the blades about
their longitudinal axis; however, the cam gear
prevented any movement of the segment gears,
enabling the investigators to'determine the indi-
vidual blade position a t impact. Examination
showed that the fifth valley f r o m the low pitch
end of the segment gears was lined up wi+ the
 ICAO Circular
center etched line on the b a r r e l bore for the
Nos. 1 and 2 blades. The No. 3 blade segment
gear, however, had the sixth valley lined up
with the etched mark. This showed that theNos.
1 and 2 blades were positioned one segment gear
toothless, o r eight degrees less, than the No.
3 blade. compared to the low pitch stop the
No. 3 blade was positioned a t 24 degrees, the
normal position, while Nos. 1 and 2 blades were
a t 16 degrees, eight degrees l e s s than the nor-
m a l positiop.
To determine the possibility of oil leakage
and, if existent, the amount of leakage f r o m the
loose dome assembly, the propeller was r e a s -
sembled using replacement p a r t s only where
necessary; the dome and b a r r e l assembly f r o m
the original propeller were used. The exact
dome looseness was duplicated on a propeller
t e s t stand and oil was pumped into the propeller
assembly a t various p r e s s u r e s . The tests r e -
vealed that there was oil leakage a t all pres-
s u r e s and that the maximum oil p r e s s u r e obtain-
able was 200 p. s . i. (pounds p e r square inch),
because of a n 18-quarts per minute oil leakage
p a s t the loose dome, At this time the pumpwas
operating under test conditions which would nor-
mally produce about 6 0 0 p. s. i. The t e s t further
showed the oil supply of the engine would rapid-
ly be exhausted. (Oil capacity per engine is
20 gallons. )
The No. 4 engine was examined in detail.
This revealed that the r e a r m a s t e r rod bearing
was in the process of failure. It also showed
the front m a s t e r rod bearing was beginning to
fail. Examination of the bearing failures show-
ed they were characteristic of those associated
with oil starvation. Neither, however, had pro-
gressed to the extent that i t would be expected
to appreciably affect the operation of the engine
o r its power capability. The engine examination
disclosed no other evidence of malfunction o r
failure.
According to company witnesses and r e -
cords, the No. 4 propeller had been overhauled
on 7 September 1955 and thereafter installed on
another company DC-4. On 11 November 1955
i t was removed a s a result of a pilot roughness
complaint applying to it o r the No. 4 engine.
The propeller was examined, repaired, and
tested, after which i t was installed by Peninsu-
l a r maintenance personnel on the subject a i r -
craft in the No. 4 position. Maintenance per-
sonnel stated a new propeller dome seal was
used during this installation. At the time of
the accident the propeller had accumulated 475
hours since the major overhaul and 20 hours
since this last installation.
During a portion of the 20 hours the a i r -
craft was flown to Kansas City and to McChord
Air F o r c e Base, Tacoma. This flight was un-
eventful except for a failure of the No. 4 s t a r t e r
solenoid a t Billings, Montana. There were no
adequate r e p a i r facilities at Billings so the a i r -
craft (after an a i r s t a r t on No. 4 engine) was
flown to McChord Air Force Base on 13 Novem-
b e r and f e r r i e d to Boeing Field where the cap-
tain contacted Seattle Aircraft Repair Inc., and
requested them to replace the No. 4 s t a r t e r
solenoid and to c o r r e c t other discrepancies
noted and/or written up during the p;evious
flight.
The captain instructed the repair agency
to examine the No. 4 engine to be s u r e it was
not damaged in any way by the a i r s t a r t . The
crew noted an accumulation of oil on the right
wing in the a r e a of the engines and brought i t to
the attention of maintenance personnel for cor-
rective action. Without cleaning the oil f r o m
the a i r c r a f t and running the engines to determine
the source of leaking oil, the employees con-
cluded f r o m visual inspection that the leak came
f r o m the Nos. 3 and 4 propeller dome seals.
During the public hearing the mechanics
and helpers who worked on the a i r c r a f t , and par-
ticularly on the No. 4 propeller, were called to
testify. In connection with the personnel work-
ing on the No. 4 propeller, the helper had r e -
cently been employed and the CAA certificated
mechanic in charge had not replaced dome s e a l s
for three years. Neither employee was familiar
with the experience and capability of the other
o r the prescribed procedure to be followed in
correctly replacing the dome seals. These wit-
nesses, through their testimony, showed there
was no clear line of responsibility within the
company nor were there reference manuals to
define their specific work procedures.
Witnesses testified that the work on the
No. 4 propeller was done under adverse weath-
e r conditions. It was accomplished outside in
very cold weather and with considerable snow
falling. The two employees who worked on the
No. 4 propeller, said that an accumulation of
oil was evident under the right wing and around
the propeller dome. The Nos. 3 and 4 domes
were removed and, according to testimony, the
No. 4 seaL was found gouged. New seals were
then obtained f r o m the company supply, warmed,
and instailed in the domes. The mechanic help-
e r said he assisted in placing the No. 4 dome in
position, turned the dome retaining nut on a few
threads, and left the job to go home. The em-
ployee in charge of this work said that with the
assistance of his helper he tightened the dome
206 ICAO Circular 5 0 - ~ ~ / 4 5
retaining nut with a dome wrench. He further
stated that he was satisfied i t was tight and
that he had replaced and safetied the lock screw.
Testimony of the witnesses clearly showed that
during the work the propeller was not feathered,
a s required by good practice, and the positions
of the blades were not checked either before
the seal was installed o r after the work was
completed. An inspection of this work was
made by an authorized employee but consisted
only of a check to see if the lock screw was
safetied. It was also learned that neither this
engine nor any of the others was run up a t any
time to determine the adequacy of the mainte-
nance.
While the maintenance work described
was in process, a No. 1 inspection was o r d e r -
ed by Peninsular Air Transport officials f r o m
Miami. This was completed, according to
numerous witnesses; however, the records
were apparently destroyed, being aboard the
a i r c r a f t when it crashed. Company instructions
required that one copy of the inspection be mail-
ed to the home office; however, the captain did
not do this but instead put all the records inthe
flight log.
Testimony of the flight crew indicated
that they a r r i v e d a t the Boeing Airport about
1900 on 17 November. They stated that they
went to the Seattle Aircraft Repair office and
were unable to contact anyone who could inform
them concerning the work performed on the a i r -
craft, o r the readiness of it for flight. They
returned to the terminal thereafter and began
preparation for the flight, contacting the weath-
e r office and completing other necessary de-
tails. Another t r i p to the r e p a i r agency office
was made with the s a m e results a s the f i r s t ,
after which they again returned to the terminal
and found the Vice-President of Seattle Aircraft
Repair. According to the captain and the f i r s t
officer he informed them that the a i r c r a f t was
ready for flight and that a l l the maintenance
work had been completed. The captain further
stated he received the No. 1 inspection form,
the daily flight check form, and the repair
forms on the work he had ordered. Although
not s u r e who had told him, the captain said he
was told that the engines had been run up. He
further stated that the f o r m s given him indicated
the engines had been run up and that the a i r c r a f t
was signed off a s airworthy. The crew testified
that following this they went to Seattle Aircraft
Repair to get their aircraft. They performed
a walk-around inspection, noting that the evi-
dence of oil had been cleaned f r o m the No. 4
engine. They started all engines, running them
a t low r . p. m. for approximately 10-20 minutes
until they were warm. The a i r c r a f t was then
taxied to the terminal for loading.
The Vice-President of Seattle Aircraft
Repair testified that the crew did not contact
him until after the a i r c r a f t had been brought to
the terminal. He stated the crew brought the
a i r c r a f t there without knowledge of whether i t
was ready and without having the various work
forms. The witness indicated that the engines
were not run up during the nonroutine mainte-
nance work on the propellers. He added that
following the type work accomplished on the No.
4 propeller a runup would n o ~ m a l l ybe required.
Following the other work, the daily inspection
and No. 1, the runup was not done because of
the extremely heavy workload upon his organiza-
tion. He added that the forms given the crew
did not indicate the engines had been run andthe
subject was not mentioned during any conversa-
tion with the Peninsular crew. He said he sign-
ed the f o r m s given the crew, indicating the a i r -
craft was airworthy.
Weather conditions were substantially a s
reported by the Weather Bureau - ceiling 1 600
feet broken, 2 300 overcast, visibility 7 miles.
The crew said that after the a i r c r a f t was cleaned
of snow there was no precipitation and thus no
chance of ice forming on the aircraft. The
weather observer stated that in his observations
during the period between 2300-2400 he c a r e -
fully watched for signs of freezing r a i n but there
were none. The captain said that visibility was
good, that weather conditions did not affect the
course of his action, and that a t no time was the
a i r c r a f t high enough to encounter the clouds.
The crew stated the pretake-off checks
were comprehensive and were completed while
waiting their turn to take-off and just after
taking position on the runway. During the checks
the engines were run up to approximately baro-
m e t r i c p r e s s u r e (30 inches of manifold pressure).
Nos. 2 and 3 engines were run up together and
then Nos. 1 and 4 together. The crew said no
roughness was observed o r felt, The co-pilot
stated he used the ice light to observe Nos. 3
and 4; however, the captain did not r e c a l l i t
being used. The propellers were exercised at
least four times before the response was nor-
mal for Nos. 3 and 4 propellers. The custom-
ary feathering checks were made.
The captain testified that he made the take-
off f r o m the left seat. As was his habit under
the existing conditions, control of the a i r c r a f t
was accomplished principally by reference to
 ICAO Circ ular 50-AN/45 207

instruments. Both pilots agreed the take-off T e s t s were made to determine what, if
and climb were normal until the f i r s t power re- any, roughness existed a s a r e s u l t of the improp-
duction, 300-400 feet above the ground, a t an e r l y indexed propeller blades of the No. 4 pro-
airspeed of approximately 120 knots, and with peller. The blade configuration of the accident
a rate of climb of between 500 and 1 000 feet a i r c r a f t was intentionally duplicated on an out-
p e r minute. The captain felt the a i r c r a f t yaw board propeller of another DC-4. Running that
to the right when the No. 4 r . p. m. surged a t engine only, i t was noted that vibration could be
the f i r s t reduction of power and again when the felt in the cockpit with noticeable swaying of the
power on No. 4 was reduced. The r a t e of magnetic compass unit mounted by shock cords.
climb immediately decreased and a s the engine The vibration was apparent around 1 000- 1 200
and propeller began to overspeed an unsuccess- r. p. m. and was visually noticeable by watching
ful attempt to feather was made. Both pilots the engine shake on i t s mount. The vibration
noted a reaction f r o m the propeller and momen- was evaluated a s s e v e r e a t the aforementioned
tarily i t appeared that the propeller was feath- r.p. m . , becoming l e s s apparent with increased
ering. The co-pilot said he noted a reduction r . p. m. In the experience of the testing group
in r . p. m . to about 1 500-1 800 which the cap- s e v e r a l instances of blade misindexing were
tain said he felt when the yaw was momentarily known, nearly all of which w e r e discovered dur-
relieved. Take-off power was added to all but ing ground runup of the engines. At l e a s t one
No. 4 engine. Immediately thereafter the r.p. m. s i m i l a r condition on a like a i r c r a f t went unno-
of No, 4 increased to more than 3 000 which, ticed during flight operation.
after consideration, the co-pilot felt was n e a r e r
3 500. This was accompanied by a loud propel- The Peninsular crew stated that after
l e r whine, heard by the crew and numerous per- reaching the a i r p o r t on 17 November and talking
sons on the ground. The co-pilot said he felt with the Vice-President of Seattle A i r c r a f t Re-
the feathering button which was still in, the po- pair, Inc., they w e r e a s s u r e d the a i r c r a f t was
sition to actuate feathering. He pulled the but- ready for flight. They stated that the maintenance
ton out, pushed it back in, in a second attempt f o r m s given them were reviewed and showed the
to feather; there was no response. The captain work ordered had been done. Because of con-
stated that the a i r c r a f t was descending during flicting recollections i t i s not known when this
this time, and he raised the nose of the a i r c r a f t occurred, before o r after the a i r c r a f t was taxied
in an attempt to hold altitude a t a slower a i r - to the terminal.
speed. He related that he did not use t r i m to
alleviate the heavy yaw, stating he could hold
directional c ~ n t r o without
l t r i m and he was bet- Testimony of the maintenance personnel
showed clearly that a t no time after the a i r c r a f t
t e r able to feel his a i r c r a f t without it. He also
stated that the No. 4 propeller drag felt insur- was received for maintenance on 14 November
mountable and i t was impossible t o gain o r even were the engines run up. The Board i s of the
hold altitude. The captain then concentrated on f i r m opinion that such a runup was essential to
a vital p a r t of the work performed on the Nos.
crashlanding the a i r c r a f t with a s slow an a i r -
speed a s possible and in the l e a s t populated 3 and 4 propellers and a responsibility of the
maintenance agency. This was important in
a r e a . He therefore allowed the a i r c r a f t to turn
away f r o m a hill toward a flatter area. o r d e r to determine if the dome s e a l s had been
Both
crew members said full power was applied to properly installed and if there were any leaks.
It was even m o r e n e c e s s a r y because the main-
all engines and the a i r c r a f t hit tail f i r s t in a
full power stall. tenance personnel had concluded that the original
leaking oil came f r o m the propeller dome s e a l s ,
During the public hearing a qualified rep- without f i r s t cleaning the engines and thereafter
resentative of the propeller manufacturer testi- running them to b e s u r e . Had the engines been
fied concerning the drag which would be expected run up following the work and the propellers
f r o m the improperly indexed propeller blades of exercised, the loose dome condition of No. 4
the aircraft. The witness stated that according would have been immediately evident by leaking
to engineering data under the following condi- oil around it.
tions, blades properly indexed a t 24 degrees,
sea level condition, airspeed 115-150 m.p. h.,
engine r . p . m . 1 586, propeller drag was 570 As shown by numerous expert witnesses,
pounds. Under the same conditions except with including a representative of the propeller manu-
the propeller blades indexed a s found on the ac- f a c t u r e r , i t was published procedure to change
cident aircraft, two at 16 degrees and one a t 24 the dome s e a l s with the propeller blades feath-
degrees, the propeller drag was 1 360 pounds, ered. This was not done and such omission i s
o r about 2 . 3 trines g r e a t e r . not considered to be acceptable maintenance.
 208 ICAO Circular 5 0 - ~ ~ / 4 5
I t i s evident that had the c o r r e c t proce-
d u r e s been followed during the dome seal change,
improper positioning of the blades would not have
occurred. It i s further believed that a thorough
engine runup would have revealed this e r r o r .
The Board therefore i s of the opinion that
good maintenance practices and procedures dic-
tated a n engine runup. It was the responsibility
of Seattle A i r c r a f t Repair, and only poor super-
vision, a n over-extended workload, and poor
maintenance procedures were responsible for
the omission.
As the result of t e s t s the Board i s also of
the opinion that considerable roughness would
be caused by the improperly indexed No. 4 pro-
peller blades, especially when the a i r c r a f t en-
gines were warmed up before the a i r c r a f t was
taxied to the terminal and while i t was holding
before take-off. Considering that all four en-
gines were used during taxi and two engines were
run up together prior to take-off, i t i s possible
that the roughness would not be noticeable unless
the crew carefully looked a t the No. 4 engine
with their Aldis lamp and/or ice light. Had
this been carefully done it i s believed the rough-
n e s s could have been detected.
As indicated, when the crew made the f i r s t
power reduction the No. 4 propeller did not re-
spond. This was undoubtedly the r e s u l t of insuf-
ficient oil supply to the propeller governor to
actuate the propeller mechanism toward a higher
blade angle. It i s believed that sufficient feath-
ering oil existed to s t a r t the process, but soon
ICAO Ref: ~ ~ / 4 2 6
after the blades started to move the supply was
exhausted. Exhaustion of feathering oil resulted
in the blades returning to the low pitch setting
with an attendant engine overspeeding. Th_is
sequence of events i s substantiated by the obser-
vations of the flight crew when they noted a mo-
mentary reduction of r .p. m . and a decrease in
rudder p r e s s u r e during the feathering attempt
and by the engine and propeller sound described
by ground witnesses. Considering the drag a s
shown by the engineering data, and that described
by the captain, continued flight under these con-
ditions was extremely difficult, if not impossible.
During the sequence of events the oil sup-
ply of the No. 4 engine became exhausted during
the attempted feathering operation following
take-off. AS shown by the oil leakage t e s t s , the
total supply ( 2 0 gallons) was not entirely exhaust-
ed during flight but s e v e r a l gallons must have been
lost before take-off. It i s very probable that this
occurred during the power check, the feathering
check of the No. 4 propeller, and when that pro-
peller was exercised. It i s not known whether
the leak could have been seen f r o m the cockpit
under the existing conditions and circumstances.
Probable Cause
The probable cause of this accident was
the excessively high drag resulting f r o m the im-
properly indexed propeller blades and inability
to feather. These conditions were the result of
a s e r i e s of maintenance e r r o r s and omissions.
210 ICAO Circular 5 0 - ~ ~ / 4 5

-
No. 49

Syrian Airways, DC-3, YK-ADD, burned in hangar following explosion

a t Damascus Airport, Syria, on 22 November 1955.
Report released by Department of Civil Aviation,
Ministry of Public Works and Communications, Republic of Syria.

(This report i s included f o r information only and is

not listed on the classification table. )

Circumstances The possibility of the failure of the

At approximately 1607 hours local time
the a i r c r a f t was in the hangar undergoing a 250
hours check when following an explosion a f i r e
occurred in the baggage and radio section of the
fuselage. The radio equipment was destroyed
and a large hole burned through the right side
fuselage skin. All instruments in the cockpit
a r e a were damaged and badly burned. The f i r e
extended into the main cabin and damaged the
seats and lining to some extent, also the fuselage
top skin was subjected to heat deterioration. No
f i r e damage was sustained by the wings, tail
group, undercarriage, engines o r propellers.
Investigation and Evidence
The seat of the f i r e was in the region of
the radio equipment and the explosion of petrol
fumes took place beneath the floor level, the
major effect occurring in the confined a r e a be-
tween the tanks in the control cable channel.
The side walls o r bulkheads of this channel
were forced outwards, shearing the retaining
rivets and the force was enough to damage the
main fuel tanks, the ends of which now conform
to the shape of the damaged bulkheads. The ex-
plosion a l s o ripped open the inspection doors
along the bottom of the centre section forcing the
hinges out of position. It is significant that while
the foregoing damage was quite severe, no f i r e
o r smoke damage was apparent.
In considering the evidence given by wit-
nesses, the f a c t o r s which might have been con-
tributing causes of the f i r e a r e a s follows:
a) cleaning inside the a i r c r a f t with petrol;
b) the failure of the hydraulic accumulator;
c ) the use of an extension lamp with an
inadequate guard.
hydraulic accumulator being the cause of the
f i r e was effectively disposed of by one witness,
who was standing at the forward cabin door
after the f i r e had been partially extinguished
and covered with hot hydraulic oil by a sudden
gush, evidently the moment of failure of the
accumulator.
The s a m e witness disposed of the possi-
bility of the extension lamp causing the f i r e by
stating that he removed the lamp f r o m the a i r -
craft in good condition.
The use of petrol in a n open container
for cleaning purposes was thoroughly discussed,
and i t i s felt -that the accumulation o i petrol
fumes i n the confined a r e a at the front of the
fuselage would create a condition of concentrated
fumes conducive to an explosion and subsequent
fire.
In this connection the committee estab-
lished that an open pail two thirds full of petrol
was being used for cleaning the control cables
at the front section of the fuselage, that the pail
was located between o r near the pilots1 s e a t s ,
that it was there for about twenty minutes, and
that the cables were being cleaned by dipping a
rag intp the petrol and rubbing the cables.
It i s considered that the foregoing cir-
cumstances were ideal for causing a f i r e and
the ignition of the petrol fumes was carefully
considered under the following subjects:
A. Radio: Cine witness stated that he
saw a blue flash coming out
of the radio equipment. This
i s discount,ed by the radio
specialist As being hardly
possible particularly since
a l l the switches were in the
'off' position, and by the-
radio engineer, who stated
 ICAO Circular 5 0 - ~ ~ / 4 5 2 11

that the wiring and connections It i s significant that one workman who
of this installation were in sustained a badly burned hand states that the
good condition and were ground- burn was caused when he unthinkingly stretch-
ed. ed out his hand in a n effort to help the boy who
was working with him. T h e r e was a distance
B. Electrical Wiring: Since much of the of about 1 1/2 m e t r e s between them, and it i s
-
wiring was burned i t was diffi- felt that if he stretched out his a r m through o r
cult to locate an indication of into the f i r e he would have sustained a more
failure, but again the switches extensive burn. It i s m o r e likely that his hand
being 'off 1 the possibility i s was at the actual point of ignition and that the
remote. initial flash burned the back of his hand, and
his evidence i s discounted a s an effort to protect
C. Very Pistol: The accidental discharge himself f r o m possible criticism.
of the Very signalling pistol
was considered, but t h e pistol It i s a well established fact that petrol
was found intact in its holster, fumes can be ignited by the s m a l l s p a r k produc-
and the cartridges showed no ed by two metallic surfaces being struck togeth-
signs of discharge. e r and it must be noted that one worker, who
was working in the nose section of the a i r c r a f t ,
D. Extension Lamp: The breaking of the distinctly heard sounds of hammering coming
bulb. and conseauent s ~ a r was k f r o m the cockpit a r e a . It i s , therefore, r e a -
considered a t some length, but sonable to conclude that the explosive fumes
since the lamp was removed which accumulated over a period of twenty
after the f i r e this possibility is minutes were s e t off by a static spark which
ruled out. However, i t was was created by one of the workmen inside the
demonstrated that the guard on a i r c r a f t in the course of doing his normal work.
the lamp i s inadequate, and
that the bulb can quite easily Probable Cause
be broken.
The explosion and the f i r e were caused
E. Static Discharge: The possibility of an by the ignition of highly inflammable fumes in
electrical discharge caused the forward part of the a i r c r a f t and the ignition
either by atmospheric condi- was caused by some action of the workmen who
tions o r by the dropping of a were working there at the time.
tool o r merely by rubbing the
s t e e l cables with a damp rag Observations
i s considered quite logical.
The use of petrol in open containers in
The Chief Inspector stated that the use of confined a r e a s i s considered a highly dangerous
petrol f o r cleaning purposes i s normal practice in practice and contrary to accepted good mainte-
Syrian Airways and the Chief Engineer a g r e e s nance methods. It i s comparatively safe to use
that this i s a dangerous practice, although he dis- in the open, but the natural fumes which a r i s e
claims any knowledge of the use of open .containers in an enclosed section create a definite f i r e
inside the aircraft. hazard.

The atmospheric conditions on the day of While not within the specific scope of the
the f i r e were conducive to electrical discharges, committee, it i s felt that some observations on
but the possibility i s considered remote since the the f i r e prevention facilities available a r e in
a i r c r a f t was off the ground and on jacks. o r d e r . F i r s t , it i s apparent that no f i r e d r i l l
i s given to the employees since no attempt was
The dropping of a tool onto a metal member made to extinguish the f i r e . Secondly, one wit-
can definitely produce a spark which will ignite n e s s had difficulty in releasing the C02 hose
petrol fumes and the work being done a t the time f r o m the a i r p o r t f i r e truck, having to use con-
of the f i r e leaves this a definite possibility. siderable force t o get it f r o m under another
hose. Thirdly, it has been stated that when the
It i s quite possible to create surface elec- hose was finally released and operating it was
tricity by rubbing metal with a rag, and if the rag played on the nose of the-aircraft and not at the
i s moist with petrol the r i s k of f i r e i s v e r y high. s e a t of the f i r e .
212 ICAO Circular 5 0 - ~ ~ / 4 5
Recommendations
To prevent a s i m i l a r occurrence in the
future i t i s recommended: -
1. that Syrian Airways cease using petrol
f o r cleaning purposes inside a i r c r a f t ;
2. that adequate f i r e ,extinguishing equip-
ment be placed in the hangar;
3. that adequate f i r e d r i l l be given to
hangar employees;
ICAO Ref: ~ ~ / 4 1 7
4. that a properly licensed engineer be
in charge and be actually present to
supervise a l l major checks;
5, that extension lamps be provided with
g u a r d s which will prevent accidental
breaking of the bulb;
6 . that the batteries be removed f r o m the
a i r c r a f t a t a l l major inspections.
 ICAO Circular 5 0 - ~ ~ / 4 5
-
No. 50
C-47, PP-CCC, crashed near Bel6m Airport, Belhm, P a r 6 on 1 December 1955.
Brazilian Commercial Accident Report No. 13-C-55, released 15 March 1956.
Circumstances
The a i r c r a f t took off a t 0957 hours Green-
wich Mean Time f r o m Be1k.m Airport, carrying
4 crew and 2 passengers, and had climbed to ap-
proximately 100 to 250 m e t r e s when the pilot not-
ed signs of malfunctioning in the left engine. A
violent stall and l o s s of power in this engine fol-
lowed although the propeller continued to revolve.
No emergency message was sent and the pilot did
not p r e s s the feathering control. However, the
r e s t of the emergency procedure appears to have
been c a r r i e d out o r to have been in progress a t
the time of the crash. The hydraulic pump was
off and this had the effect of stopping the r e t r a c -
tion of the undercarriage half-way. The aerody-
namic resistance of the semi-retracted undercar-
riage prevented the a i r c r a f t f r o m maintaining
altitude, carrying it down to 20 o r 30 metres
above the t r e e tops, possibly without this being
noticed. There i s reason to believe that the pilot
was in the act of switching the fuel selector f r o m
one tank to the other when the left wing tip hit a
t r e e breaking off 2.5 metres of the wing and half
the aileron. The aircraft swerved 20 degrees to
the left and nosed-up violently, The right engine
a t this time was on full power. The a i r c r a f t stall-
ed and hit the ground 200 m e t r e s f a r t h e r on. Ex-
plosion of the fuel tanks and f i r e followed. All
occupants were killed.
Investigation and Evidence
At the time of the c r a s h the flap control
lever was in the retracted position (routine), the
trimming tabs were on the proper setting, the
propeller pitch control appears to have been s e t
almost to the "minimum1*position (as it was found)
and the fuel selector was being switched f r o m the
main to the auxiliary tank o r vice versa.
It appears that at that time while still fly-
ing some 30 to 40 m e t r e s above the t r e e s and hav-
ing close-by, on his left, the clear a r e a of the
teletype station and other a r e a s with low shrubs
extending to the r i v e r ' s edge, the pilot still con-
sidered himself in comparative safety. It i s ,
therefore, believed that the emergency operations
claimed his attention within the cockpit, partly
distracting i t f r o m outside obstacles. This would
also account for the right engine not being a t full
power.
213
It was proved during the inquiry that
although the left propeller was revolving, i t
was doing so f r e e l y i. e . , disconnected f r o m
the engine, which had stopped some time be-
fore. It i s assumed that, believing the under-
c a r r i a g e to be fully retracted and seeing the
left propeller s t i l l revolving, i t did not occur
to the pilot to switch the hydraulic s y s t e m
selector to the right engine.
It i s assumed that the failure of the left
engine probably occurred a s follows: -
1 - Breakage a t one point of the r e a r
bearing spacer of the propeller shaft,
allowing one o r more r o l l e r s to oper-
a t e outside the raceway and cause
distortion of the whole.
2 - Material disintegrated f r o m the above
bearing, being ground between the
reduction gear and the power section
of the engine, caused intermittent
longitudinal compression s t r e s s e s on
the above-mentioned bearing and on
the front bearing of the power section.
These s t r e s s e s led to fatigue f r a c t u r e
of the r i m of the inner raceway of the
f o r m e r bearing and of the outer race-
way and casing flange of the latter one.
3 - The above process, which must have
gone on for some time, finally led to
f r a c t u r e of the casing flange of the
second bearing, which then came out
of alignment and slipped backwards,
thus disconnecting the power section
and ultimately the propeller.
4 - In moving backwards, this bearing
came into contact with the middle g e a r
controlling the valve plate, disengag-
ing i t f r o m the g e a r which operates i t
(c ~ a n k s h a f tcoupling gear). When
this occurred, the valve plate was
thrown off phasing, so that explosions
occurred out of timing throughout the
forward bank o t c y l i n d e r s , causing a
back-stroke on the crankshaft, tending
to s t a l l it.
2 14 ICAO Circular 5 0 - A ~ / 4 5

5 - At the same time, there occurred a Probable Cause

breakage of the end of the axle of the
middle valve plate gear, which operates
the propeller governor. The oil supply
pipe f o r the propeller pitch control may
also have been broken. Consequently,
the pitch control was inoperative.
F a i l u r e of the front bearing of the propeller
shaft originated a process which led to disconnec-
tion of the reduction g e a r and left propeller and
causing sudden stoppage of the left engine.

ICAO Ref: A~G/ACC/REP/GEN/NQ. 8

 ICAO Circular 5 0 - ~ ~ / 4 5 215

No. 51

Circumstances settled toward the ground, striking other large

The flight originated at Miami, Florida,
its destination Boston, Massachusetts with an
intermediate stop at Jacksonville, Florida. It
departed Miami International Airport a t 0212
hours Eastern Standard Time on an Instrument
Flight Rules flight plan with 12 passengers and
5 crew members. At 0331 the flight reported
over Sunbeam Intersection (16 miles SSE of
Imeson Airport), was cleared for an ILS approach
to Runway 5 and received the Jacksonville weath-
e r report - "Partial obscurement, visibility one-
half mile; altimeter 30.18." This was followed
immediately by another message - I1Coming out
with indefinite 300 obscurement now one-half
with fogt1,* After acknowledging this information
the flight reported leaving Sunbeam a t 2 500 feet.
Following a l a t e r query f r o m the flight, approach
control advised that there was no other known
traffic in the a r e a . Flight 642 reported over the
outer marker inbound a s requested and was clear-
ed to land. Shortly thereafter the tower control-
l e r observed a large flash in the vicinity of the
ILS middle marker. F u r t h e r calls to the flight
were not acknowledged and i t was subsequently
learned that the airdraft had crashed a t 0343
hours approximately six-tenths of a mile south-
west of the threshold of Runway 5. All 17 occu-
pants were killed.
t r e e s which disintegrated both wings and a
portion of the empennage. Ground contact was
on a heading of approximately 55 degrees mag-
netic. The distance f r o m the f i r s t t r e e struck
to the farthest piece of wreckage was 801 feet.
Explosion and f i r e occurred immediately upon
impact.
The cabin and cockpit a r e a s were com-
pletely consumed in the ground f i r e with the
exception of the lower fuselage skin and por-
tions of the cabin flooring. The f u s e l a g e aft of
the r e a r p r e s s u r e bulkhead and the center rudder
fin and portions of the stabilizer were intact,
but with surface scorching indications. The
tail cone was found in a relatively undamaged
condition with the control booster mechanisms
in proper position.
Outer portions of the left and right wings
had been separated f r o m the main structure
during the passage through the t r e e s and along
the ground. The llspeedpacklt(a l a r g e detachable
cargo compartment positioned on the underside
of the fuselage) was t o r n f r o m the bottom of the
fuselage a t ground impact. Wing flaps were
determined to have been in the 60 percent exten-
sion position, and their positions were symme-
t r i c a l at the time of impact.

Investigation and Evidence Separation of the right main g e a r and

part of the nose gear had occurred a t ground
Investigation disclosed the main portion of contact. The left main gear was intact and in
the wreckage to be 212 feet northwest of the ILS the extended and locked position; the cockpit
middle marker and 3 486 feet southwest of the landing gear lever was found in the Itdownt1posi-
threshold of Runway 5. tion. Measurement of the right main gear actuat-
ing cylinder piston rod revealed the s a m e 15
F i r s t impact of the a i r c r a f t was with the inches a s found on the down and locked left
top of a s m a l l pine t r e e approximately 200 feet main g e a r actuating cylinder piston rod.
below the ILS glide path, 260 feet to the left of
the extended centerline of the runway, 4 000 feet All boost control assemblies were found
f r o m the threshold of Runway 5, and 420 feet in the "boost oni1position. A bench check r e -
southwest of the middle marker. This was fol- vealed that a l l boost actuating cylinders had
lowed by striking a 50-foot oak t r e e , the upper normal travel in both directions and showed no
20 feet of which were sheared off. The a i r c r a f t signs of abnormal internal leakage. Relief valves

* Eastern Air Lines1 Constellation minima f o r ILS approaches at Jacksonville, day o r night,
a r e ceiling 200 feet, visibility one-half mile.
 216 ICAO Circular 50-AN/45

and bypass controls operated normally. The heard just before impact. h e witness, who
filters showed a normal differential p r e s s u r e was near the middle marker, said he f i r s t saw
between inlet and outlet. The elevator boost was the landing lights, lighted and pointing straight
installed in a similar aircraft, was flight tested down, and that they partially extended before
and found to function in a normal manner. he lost sight of the a i r c r a f t . Other witnesses
near the accident scene did not s e e the landing
On impact the four powerplants separated lights on. Subsequent investigation disclosed
at their attach points and came to r e s t a few feet that the right landing light had been destroyed
ahead of the main wreckage. Number 4 engine but the left light was found in the retracted
suffered extensive damage in the ground f i r e . position. There was no f i r e observed by any
Examination of the interiors of all four crankcases witness prior to impact. One witness saw the
gave no indication of rotational o r reciprocating a i r c r a f t , at a very low altitude, make a slight
interferences o r operating irregularity of any turn to the right just before it contacted the
kind. All oil pumps were f r e e of metal particles t r e e s and ground.
and revealed no scoring. There was no evidence
to indicate that the engines were not capable of A witness who was driving a trailer--
developing power prior to impact. truck south along the highway adjacent to the
airport said he saw what he believed to be two
All propeller blades were broken o r bent, jet-propelled a i r c r a f t pass f r o m right to left
with bending generally rearward, and five of in front of him, flying a t an altitude of 150-250
them were broken a t the butt ends. The dome feet. He stated that a t the same time he observ-
position and blade angles were found to be in sett- ed these a i r c r a f t he saw a bright flash, where-
ings that indicated normal operation of all engines. upon he immediately stopped his truck and
walked down the highway. To his right he saw
The tearing f r e e of a l l powerplants result- scattered parts of an a i r c r a f t burning. He also
ed in the pulling and breaking of control cables said that before reaching the a i r p o r t he had
under tension. Several of the cable-controlled passed through patches of ground fog, that at
fuel shutoff valves were found in the closed posi- the a i r p o r t t h e r e was an overcast condition,
tion; the electrically controlled firewall fuel shut- and that he again passed through patches of
off valves were all open. ground fog a s he continued south.

F r o m markings presented by ground object

contacts of the a i r f r a m e and propellers it was
determined that just prior to impact the a i r c r a f t
was in a slight turn to the right and banked ap-
proximately 11-1/2 degrees. The longitudinal
attitude of the a i r c r a f t was approximately 4-3/4
degrees nose-up and the angle of descent during
the last 200 feet of the flight path was about 2-1/2
degrees, with the r a t e of descent being 10 feet per
second.
Several flight checks of ground navigational
facilities soon after the accident showed operation
of the systems to be normal. Simulated ILS ap-
proaches were made, with a Board investigator
a s observer, to determine the effect on cockpit
instruments caused by vehicles parked on the
highway below the glide path. The highway i s
about 100 feet east of the middle m a r k e r . On one
approach, with a crane-equipped truck parked
beneath the glide path, a flydown indication was
noted prior to reaching the middle m a r k e r . It
was necessary to descend 60 feet in o r d e r to
center the needle. However, the glide path indi-
cation was found to be normal a t the middle mark-
e r , where the accident occurred.
Several persons saw o r heard the aircraft,
with normal engine sound. A power surge was
The two a i r p o r t tower controllers in
radio contact with the flight stated they heard
it pass over the south edge of the field, proceed-
ing outbound. At this time the runway lights
were on a t their highest intensity. One of the
two controllers on duty stated that he went
downstairs to the r a d a r room and, on the Air-
port Surveillance Radar scope, observed the
flight just before it reached the outer marker
outbound. He also said he saw the s t a r t and
completion of a procedure turn and observed
the a i r c r a f t s t a r t inbound, after which he gave
the flight its three-, two-, and one-mile range
positions. The tower recording of outgoing
messages does not include the three-mile posi-
tion message. The ASR equipment at Jackson-
ville does not show altitude above the ground.
The controller stated that forward movement
ceased soon after the image of the a i r c r a f t on
the scope passed the one-mile position f r o m
the end of the runway. This r a d a r observation
coincides with the geographical position of the
crash. During the entire time the controller
was watching the scope, s e t to 10-mile range,
he saw no other aircraft. Comprehensive -
investigation revealed no other traffic, either
civil or military, in the a r e a during the ap-
proach of the subject aircraft.
 ICAO Circular 5 0 - ~ ~ / 4 5 217

The night of December 20-21 weather sta- condition existing a few miles to the southwest.
tions f r o m Miami to Savannah, Georgia, were. All other a r e a s appeared to be clear. It there-
reporting a small s p r e a d between temperature fore appears likely that the flight was c l e a r of
and dewpoint. The company terminal f o r e c a s t clouds f r o m the Sunbeam intersection to the
for Jacksonville was ceiling and visibility unlim- middle m a r k e r and outbound to the outer marker
ited; this was not amended until 0345 when it was and that i t probably did not encounter obscure-
changed to ceiling 300 feet, broken clouds; visi- ment until in the vicinity of the middle m a r k e r
bility three-fourths of a mile; fog. During the inbound. Although this weather condition has
briefing the company f o r e c a s t e r advised the crew been described a s partial obscurement with
that patchy ground fog could be expected in the horizontal visibility of one-half mile, i t i s ap-
Jacksonville area. parent f r o m the testimony of pilots that vertical
visibility throughout the a r e a was generally
It i s evident that all components of the ILS good. Some of the witnesses said the ground
system were operating normally a t the time of visibility at and near the accident was poor.
the accident. This was also indicated by another There i s no way of determining ceiling height
flight which made an ILS approach and landing o r visibility distance a t the accident site. How-
approximately 15 minutes before the accident. ever, the weather information reported to the
At that time the s y s t e m was normal, a s it was on crew was obtained a t the control tower. The
two approaches made several hours after the ac- tower i s located approximately one mile north-
cident. Monitoring r e c o r d s of the s y s t e m gave northeast of the accident scene. At the time of
no indication of any deviation f r o m normal opera- the accident a wind of six knots was blowing
tion during the e a r l y morning of 21 December. f r o m the north-northwest, and i t i s believed
All contacts with the flight by Jacksonville ap- that between the time of the l a s t reporting and
proach control were routine and the crew did not the accident the weather conditions at the observ-
report any operating difficulties. ation point could have moved to the general a r e a
of the accident and therefore should have been
The testimony of witnesses who observed essentially the s a m e a s that reported to the crew,
the landing lights of the a i r c r a f t come on during "indefinite 300, sky obscured, visibility 1/2
the approach and other witnesses who saw no mile and fog1'.
landing lights, i s not completely incompatible.
Since the lights were found in the retracted posi- Assuming that weather conditions were
tion it i s indicated that once lowered they might similar a t the c r a s h point and the observation
have been retracted to eliminate reflection a s the point, consideration should be given to the de-
a i r c r a f t decended into the layer of fog. Also, c r e a s e of horizontal visibility with elevation.
some witnesses heard a surge of power just be- Horizontal visibility must have been near z e r o
f o r e impact with the t r e e s , which indicates that at 300 feet above the ground. Normally, slant
the pilot was attempting a pullout. visibility down the glide path should have gradu-
ally increased a s the a i r c r a f t descended.
Every possible effort was made to account
for jet-propelled a i r c r a f t being in the a r e a when The r a d a r scope at Jacksonville does not
the accident occurred. All military s e r v i c e s reflect altitude. However, since the r a d a r oper-
said they had no jet a i r c r a f t flying in that a r e a a t ator testified that the a i r c r a f t was observed to
the time of the accident. Neither the tower p e r - fly beyond the outer m a r k e r , make a procedure
sonnel, witnesses on the airport, nor witnesses turn, and return inbound, it i s believed that
other than the truck driver near the accident this was accomplished a t the normal altitude of
scene saw any jet a i r c r a f t and such a i r c r a f t were 1 200 feet. The propeller slash m a r k s at the
not observed on the r a d a r scope. In view of the scene indicated the speed of the a i r c r a f t a t im-
truck d r i v e r ' s testimony, the Florida Air Nation- pact to be 140 knots. The company's instruc-
a1 Guard, under the direction of a CAB investiga- tions f o r this type a i r c r a f t show a recommended
t o r , made several flights (using a jet aircraft) in approach speed of 115 knots f r o m the outer rnark-
an effort to simulate the conditions described by e r to the minimum authorized altitude.
the truck driver. Each of these flights was plain-
ly visible on the r a d a r scope. It, therefore, i s Evidqnce indicates that the a i r c r a f t was
concluded that no such a i r c r a f t were in the vicini-flying in a normal manner just prior to impact
tY. and t h e r e i s no known evidence to indicate any
malfunctioning of the a i r c r a f t o r any of i t s com-
F r o m the testimony of other pilots flying in ponents. The flaps were extended to a position
the vicinity a short time prior to the accident, used for manoeuvring and this amount of flap
there was a layer of cloud, which included smoke extension i s usually used in this type of approach
and fog, capping the a i r p o r t with a general foggy until reaching the middle m a r k e r . Although the.
218 ICAO Circular 5 0 - ~ ~ / 4 5
aircraft was 200 feet to the left of course this
i s a small deviation a t that point in the approach
and only a slight correction would have been
required to again align with the runway. The
fact that the aircraft was in a slight right turn
and almost level horizontally at impact would
suggest that the pilot was turning toward the
localizer course, further indicating the aircraft
was under control.
It i s not unusual, with weather conditions
such a s existed this day, for pilots during an ap-
proach to an airport to find ceilings and visibili-
ties that vary f r o m those reported. If, on the
ICAO Ref: ~ ~ / 4 3 8
morning of the accident, the captain found the
visibility to be lower than one-half mile, it would
then have been his responsibility to execute a
missed-approach procedure.
Probable Cause
The probable cause of this accident was
that the flight encountered local fog and restrict-
ed visibility during the final portion of an ILS ap-
proach, and a missed approach procedure came
too late to prevent the aircraft from descending
into ground obstructions.
 High intensity runwoy and
green threshold lights

IMESON AIRPORT
I FIELD E L LV4TlON S2 1

@ ACCIDENT SITE
X WITNESS LOCATION

A-OL SCALE
STATUTE MILE$

E A S T E R N A I R L I N E S INC.
CONSTELLATION N 1 1 2 A
JACKSONVILLE, FLORIDA
DECEMBER 25 1955
 Figure 2
.
8 W i d e World Photo

General. v ~ e wof: the Eastern A k r Lbrcs LoeMxeed Cozibtel'latron &a& crashed on Zlaal appraaeir
at Imesrsn Airport* Jacksonville, F l o r r d n , an 21 December 1955,
 ICAO Circular 5 0 - ~ ~ / 4 5
No. 52
Pan American World Airways, Inc. , Douglas DC-7B, lost powerplant
due
- - - to - i r e in flight
.. f c. near Venice. Italv on 28 December 1955.
Civil Aeronautics Board (USA) Accident Investigation Report,
F i l e No. 1-0178, released 31 May 1956.
Circumstances
The flight originated a t Teheran, Iran, for
New York, N. Y., with scheduled stops at Rome,
Italy, and Brussels, Belgium. On board were a
crew of 6 and 42 passengers. The aircraft depart-
ed Rome at 1818 Greenwich Mean Time on an In-
strument Flight Rules flight plan to Brussels
which specified a cruising altitude of 19 000 feet.
At 1912, No. 3 engine and propeller overspeeded
and the tachometer needle swung rapidly past the
highest calibration, 3 200 r. p. m. to full deflec-
tion where i t remained. Power Was reduced on
a l l engines, the auto-pilot was disengaged and an
attempt was made to feather No. 3 propeller, with-
out success. At this time the co-pilot noticed a
flicker of the f i r e warning light for the power sec-
tion of No. 3 engine. Airspeed was reduced f r o m
200 to 140 knots and descent was started. The
f i r s t officer then reported a f i r e in No. 3 engine.
As No. 3 propeller was windmilling a t a high
speed, an attempt was made to "freezeIt the engine
by shutting off i t s oil supply. Accordingly, the
firewall shutoff valves were closed. One bank of
C02 was discharged which reduced the intensity
of the f i r e but did not extinguish it. Meanwhile
the flight engineer was intermittently depressing
the feathering button. The discharge indication on
the ammeter showed the feathering motor to be
operating but the propeller did not feather and
continued to windmill. F i r e warnings were s t i l l
lacking in the cockpit with the exception of the
momentary flicker immediately following the over-
speeding. Zone 2 and zone 3 f i r e warnings f r o m
No. 3 engine then appeared, followed by increased
f i r e at the NO. 3 engine a r e a whereupon the second
bank of C02 was discharged. The red warning
lights and aural a l a r m still operated after this
second use of C02. At this time a n intense white
f i r e was noticed through a rupture in the cowling
near the a i r scoop of No. 3 nacelle. The a i r c r a f t
then advised Rome radio that it was going to make
an emergency landing on o r near the beach of the
Adriatic Sea n e a r Venice. A descent was made to
500 feet where after a s e r i e s of bright flashes and
severe vibration the burning No. 3 engine fell f r e e
of the aircraft. Severe buffeting followed, the a i r -
speed dropped to approximately 90 knots, power
was applied to the remaining three engines and an
airspeed of 140 knots and a climb of 150 feet per
221
. -
minute w e r e soon established. A check in-
dicated that the a i r c r a f t was capable of continu-
ing flight and the crew advised Rome that they
intended to return. The landing was made at
2040 hours and there were no injuries to pas-
sengers o r crew.
Investigation and Evidence
The still burning engine was found near
Venice and following the taking of photographs
it was taken to Rome for examination and sub-
sequent shipment to Pan American's mainte-
nance base a t New York.
The propeller governor was undamaged
by f i r e and after an initial examination was
flown to the Hamilton Standard factory in the
United States where i t was disassembled under
the supervision of Board investigators. Disas-
sembly revealed a fatigue type failure of the
governor drive shaft ( P a r t No. 67035U). Initial
failure extended through the web between two of
the high pitch oil ports with resulting failure
occurring to the drive shaft through the remain-
ing webs. The f r a c t u r e line passed through one
or more quench cracks at the port webs. Total
time on the shaft was 407 hours when the failure
occurred. Examination of the remainder of the
governor revealed that broken parts of the shaft
had blocked oil ports which effectively prevented
feathering of th'e propeller.
A review of past governor drive shaft
failures of this type revealed four others that
occurred during October and December 1955.
A11 of these were in the s a m e type engines and
DC-7Bts. F u r t h e r , all were s i m i l a r in that a
fatigue failure occurred at the c o r n e r s of the
rectangular high pitch ports in the shaft. Total
times on all of the failed shafts were between
375 and 592 hours.
As a result of these failures Hamilton
Standard had revised its heat-treating procedures
todreduce quench cracking. A11 governor drive
shafts in service were returned for replacement
with those having the improved heat-treatment,
The letter after the part number (67035) on
the drive shaft involved in this accident indicates
that this replacement had been accomplished.
222 ICAO Circular 50-AN/45
In November 1955 all DC-7B operators
were advised by the propeller manufacturer that
a s a result of the failures a program was being
initiated to replace all governor drive shafts b e a ~
inp the part number 67035 with a new shaft, part
number 321822. This new drive shaft incorporates
elliptical high and low pitch ports in place of the
rectangular ports, thereby eliminating s t r e s s
concentrations in the corners. All PAWA DC-
7B Is a r e currently being equipped with the 321822
drive shaft and an r , p.m. sensitive hydraulic
pitch lock* in the dome assembly. This replace-
ment program was established by the manufactur-
e r with priority given to governors having l e s s
than 1 000 hours. Those with over 1 000 hours of
use were considered to be airworthy.
On 16 January 1956 the Civil Aeronautics
Administration issued Airworthiness Directive
56-2-2 making mandatory the replacement of pro-
peller governor drive shaft 67035 with governor
drive shaft 321822 on all DC-7 aircraft.
The manufacturer i s producing a newly
designed drive shaft which increases the web
strength between the ports by 50 percent. The
new shaft, ( P a r t Number 321841) has four oval
ports at the high and low pitch positions, thereby
increasing the web size between the ports.
An examination of No. 3 engine a t New
York indicated that i t s operation, prior to the
shaft failure, had no bearing upon the difficul-
ties encountered by this flight. The examination
* A device to prevent blade movement toward low pitch if the r . p. m. reaches a preset value.
ICAO Ref: ~ ~ / 4 3 5
0
also indicated that a s a result of overspeeding
the engine impeller assembly failed and damaged
the r e a r engine case to an extent that the fuel
injection lines in the case were broken. This
undoubtedly allowed fuel to escape, resulting in
severe fire. There was no apparent malopera-
tion of No. 3 engine prior to the drive shaft fail-
ure.
The engine impeller assembly must have
disintegrated centrifugally, throwing metal
particles outwardly through the cowling through
which was seen the intense white f i r e ; this fail-
u r e also accounted for the severed fuel lines
that provided a source of fuel f o r the fire.
The reason for the failure of the f i r e
warning s y s t e m to function properly could not
be determined because of damage to the system
during the f i r e and the tearing away of the
engine and propeller. However, in this case
there was no delay in applying emergency
measures because of alertness of the crew
member in the cabin a t the time of the over-
speeding.
Probable Cause
The probable cause of this accident was
failure of No. 3 propeller governor drive shaft
which resulted in overspeeding, inability to
feather the propeller, a n engine failure, f i r e ,
and inflight loss of the No. 3 powerplant.
 PART I1

AIRCRAFT ACCIDENT STATISTICS 1955

INTRODUCTION

GENERAL COMMENTS

1. , This section of the A i r c r a f t Accident Digest No. 7 contains a detailed analysis

of the s t a t i s t i c s for the year 1955, a s well a s a n h i s t o r i c a l r e c o r d of selected data f o r
the y e a r s 1925 to 1956 inclusive. Although figures for the y e a r s s u b s e q u e n t t o 1951
w e r e obtained l a r g e l y f r o m the ICAO A i r T r a n s p o r t Reporting F o r m s G ( A i r c r a f t
Accidents) filed by contracting States, other s o u r c e s had t o be used f o r those countries
which have not yet filed the required reporting F o r m in o r d e r t o a r r i v e a t a s complete a
picture a s possible of accidents in which public a i r c r a f t were involved.

2. The s t a t i s t i c s shown a r e the best available to date but a r e subject to adjust-

ment when m o r e a c c u r a t e data i s forwarded to t h i s Organization on the F o r m s G (fac-
s i m i l e copy given on pages 229 and 230).

DESCRIPTION O F TABLES

3. Accident data h a s been recorded under the country in which the a i r l i n e which
suffered an accident i s established and not in the country where the accident took place.
Contracting States which w e r e m e m b e r s of ICAO by December 1956, numbering 70, have
been included in a l l tables for the year 1955 and the p r e l i m i n a r y data for 1956.

4. The t h r e e tables compiled for the year 1955 give the following information:

TABLE A Fatality r a t e by contracting States whose a i r l i n e s had a n accident

causing a p a s s e n g e r to be killed on a scheduled flight.

TABLE B A i r c r a f t accident s u m m a r y by country (70 contracting States of

ICAO) of a l l o p e r a t o r s engaged in public a i r t r a n s p o r t ,

TABLE C A i r c r a f t accident s u m m a r y by type of operation and by country.

SAFETY RECORD

5. T h e r e has been a remarkable downward t r e n d in p a s s e n g e r fatality r a t e s

since 1945, indicating a steady improvement in safety in c o m m e r c i a l flying over the
p a s t twelve y e a r s . Despite the i n c r e a s e d speeds, weights and range of the a i r c r a f t
flown today a s compared with over a decade ago, the r i s k of accident o c c u r r e n c e h a s
lessened over the period largely through technical changes and g r e a t e r experience.
However, human e r r o r s a r e s t i l l a major cause of a i r c r a f t c r a s h e s and c r a s h e s brought
about by deliberate human intent cannot readily be controlled.

6. It i s to be noted that a l l accident data p r i o r t o 1952 a r e t o be r e g a r d e d a s the

best available data only, because of the fact that accidents w e r e not s o widely o r fully
r e c o r d e d in those y e a r s . With this in mind, if the safety r e c o r d i s extended to c o m p a r e
the pre-war period (1925 - 1939), with the war period (1940 1944), and the post-war-
period (1945 - 1956), i t i s found that the average fatality r a t e p e r 100 million p a s s e n g e r -
k i l o m e t r e s h a s dropped f r o m 12 in the pre-war period, t o 3 in the war period, t o 2.5
in the f i r s t s i x y e a r s after the war, and to 0.84 for the next s i x y e a r s .

7. F r o m a p e r u s a l of the c h a r t and table shown on the following pages, i t will be

observed that the fatality r a t e p e r passenger-kilometre of 0 . 7 8 for 1956 i s 25% of the
3.09 for 1945, although slightly higher than the r a t e of 0.66 in 1955. F o r the fifth con-
secutive y e a r , the 1956 r a t e h a s remained a t l e s s than one fatality p e r 100 million
passenger-kilometres flown. Although the number of p a s s e n g e r s killed on scheduled
flights o v e r the period 1952 to 1956 ranged f r o m a low of 356 p e r s o n s in 1953 t o a high
of 565 p e r s o n s in 1956, the extent of the i n c r e a s e in p a s s e n g e r traffic h a s m o r e than
o f f s e t the change in the level of p a s s e n g e r s killed thereby maintaining the fatality r a t e
below the m a r k of one.
 ICAO Circular 50-AN/45
224
- -------.---------- -------
I
--
/

PASSENGER FATALITY RATE TREND

COMPARED WITH GROWTH IN TRAFFIC
SCHEDULED AIR SERVICES 1945 - 1956

Fatality Traffic in
Rate ( B a s i s of fatality rate : number of passengers killed per 100 million Million8
passenger kilometres flown)
4 75000

3.5

60000
3

2.5
45000

30000
1.5

1
15000

0.5

0 0

1945 46 47 48 49 50 51 52 53 54 55 56

INTER NATIONAL CIVIL AVIATION ORGANIZATION STATISTICS SECTION (December 1956)

 ICAO Circular 50-AN/45 225

PASSENGER FATALITIES 1925 - 1956

-
ON
SCHEDULED AIR SERVICES

Number Fatality Rate Million8 of

YEARS of Kilometr e r p e r 100 Parrenger-
Parrengerr million Kilometrer
Killed P a r a-Kma. p e r Fatality
I

I
YEARLY AVERAGE Y

1925 - 1929 36 130 28 4

1930 - 1934 80 445 18 6
1935 - 1939 133 1 475 9 11
1940 - 1944 114 3 795 3 33

-
YEAR
1945 24 7 8 000 3.09 32
1946 376 16 000 2.35 43
1947 590 19 000 3.11 32
1948 543 21 000 2.59 39
1949 556 24 000 2.32 43
1950 55 1 28 000 1.97 51
195 1 443 35 000 1.27 79
1952 386 40 000 0.97 104
1953 356 47 000 0.76 132
1954 447 53 000 0.84 119
1955 40 7 62 000 0.66 152
1956 565 72 000 0.78 127

Exclurionr: The People'. Republic of China, USSR and other countrier not
contracting States of ICAO in 1956.

II
i
C M L AVlATlON ORGANIZATION
INT~ATIONAL 8TATISnCS SECTION (DKPMBER 1066)
22 6 ICAO Circular 50-AN/45

CONTRACTING STATES O F ICAO

PASSENGER FATALITIES OCCURRING ON

TABLE A SCHEDULED IrqTERNATIONAL AND DOMESTIC OPERATlONS

YEAR 1955

Country Country Fatality MLlLlon* of

Number Number
Total
ol
of of
Total
of
Rat.
per 100
Paas*nper -
Description Fatal Pa**enaer* KiLom8tr.r
~asaen~er MlL11on
Hour* ~ccidenta Kilied 4 ~ ( l ~ ~ pas..
~ t - ~~m . ~. . P9r
Flown

(thcud.) (.uUOM)

~n44Lss_ol~od.~d. -%so
ifm
Deleim 86 1 21 579
Brnail 428 4 26 1684
Durma 16 6 61
Colorabla 150 ' 1
1
5
3-
484
Pranae 300 10
Irulia 126 1 6 515
1.r-1 9/ U 1 51 W
Vexiw
Peru
254
23
'' 1
1
23
15
1 517
93
united Kingdm a3 3 38 3 203
United S t a t a s 3 6-13 9 197 39 U 6
Veneauela
All other S t a t e s
9@
1696 -1 -
9 325
10 994
Total 7346 25 44 62 000 0.66 1%

--oLtw
*
Selgiu 43 1 21 261
Braail 31 1 Il 272
Iernel 12 1 51 l3e
United Kingdm 339 2 29 2 765
United S t a t e s
A l l other State.
577
953 -1 2 7 238
8 826

~0t~1 1 955 6 m 19 500 0.5s 1n

WP-US
S0hedul.d W~qUppl
Bruil 397 3 15 1412
BuIou 11 1 6 40
Colombia 138 1 5 3%
Pranoe 168 1 10 1 503
India 86 1 6 W
Nexloo 202 1 23 1062
Peru 23 1 U 91
United Kingdm l4.4 1 9 519
Unitod State. 3 095 S 195 31 948
Voruswla
A l l other 8tat.s ' la*
81
-
1
-
9 199
5 167
Total 5 391 19 293 42 500 0.69 l45

&izs8

hid~td.tah.nbuo~~rtb.~Lnvhiobtb..irUnL~.t.rddmtint&wur~ub.J.th.amiWCoo*~.
Unlbr 'Totrl B U d -mtioru8 ur llat+d all ocuntrlba with w h U .irllnu nhloh hd .ooiWm ruultiq i n p...lyr
fat4Xti.r. ihn bt. h m bun rq.@tdu (o tbow Imtalltiem wmmlry o. a m W d intmmtinml tU&* +or a .ob.Qld
d o r s t i o U&t.

8- of 6.t.1 IOU) Alr Truuparl ibprtiw lo= d eutald. -m.

UhWbt.1

Data u o l u d w o m amoldont f o r h l o a k r i a (a m-r State) i n whiob 6 p s s e n p r . war. k1Il.d.

Rta imhda# o m aooident with 51 Iate1iti.s i n tha f o r w d koding of an I a n a l l &raft b r c u h t
dam a n t i - r i r o r d t f i r e i n Bulyrir.
d Dat. imludea o m aooidant with 39 fateliti*. i n tha o n a h of a U d t d Stet*. a i r o r a f t ~.ueodb,
a bmb o o n o w l d on bard.
 ICAO Circular 50-AN/ 45 22'

llPWl &wu d o.t.1 U r tmnaport R.portim# ?om O riled t onuntrlew ind1ont.P viW a 1.
All other o o d n y &ta ml1.ot.d fma outaide wuroea.
o.a.+ -
awriufd
b O i r i l Aviation.

v
i/
fi
Wr a o u bliooptw ludizw.
h t e n f o r b .irllma n g l e t e w in bhm Unit4 €&&a d ik dmpndomioa, D a U
hi- K i W a onlv P.L.l m p . p l e W 0 r m n b r 01 1UYIiw UYI h
~.t. rdrr to dl G b ~ o.ir t r w p o r t I... a n h a d UB. ~ s ~
Dab inoprpl*tm far tunbsr of W i n p .nd hour8 t b m .
1/ D.te tor U V d RUB:
dJ.
uw fkm
r
d lubair- u
- imoq1.t.
wB. $lS*j
-
fw
* mirr.
of .
) md -8

INTrRNATlONAL ClVIL AVIATION O R a A N l Z A l l O N I T A T I T I C I BECTION (December IPS

 228 ICAO Circular 50 -AN/ 45

CONTRACTING STATES OF l C A 0

1955 AIRCRAFT ACCIDENT SUMMARY FOR I955

O F A L L OPERATORS ENGAGED IN PUBLIC AIR TRANSPORT

TABLE C
p i

Number of ~...eng=r Injury C r e w Injury 0lb.rm 1n)ur.d By 0p.rmtor.

Accldenls With en Accld.nl
1 ype of 0p.r.Ilpn
Conlr.sllnp St.1c. of ICAO Number
Tolal Fats1 Fetal Serrous Fal.1 Serious M l n ~ r Fetal Srrlou. Hours
None 01
Or
Landlnl. FLown

- L
SCIffCUICD INTLRI
I p uelgim 1 1 21 - 8 - OlcU
nrasil 1 1 l l 3 - 8 2
- - 15 091
l 2 374
-
b Israel - 7
~rn.un - 2 1 - - 5 - 6 491
fi united Kingdm A/ 15 4 29 B U S 5 4 2 %W 30467l
ill
8/ -
fl Unit.d 3t1t.s
T o b l Km 6 Statnm
5
24
1
6 1 1 4
1
l a 3 8 9 3 3
1%
7 8
33
0 - 145 78q 52lm

01-
- - -
Auatnll.
nr..ii
5
3
-
1
-
5
-
36

- -
-
-
-
1
2
-
B
$ Cam&
w - 3 -
- W 329.
UOBl
178 006
Colahi.
$ Franc. 9/
1
19
1
1 10
5
f -
-
- 3 -
2
- -
2
: - 1- -
India 5 2 6 27
1 - - 2:
ILL
Hexid0
1 - -
-- --
- 3 - MaY)

-- --
p Wcu Zuland 40 lll 45 996
Ni0ar.w 1 - -
p ro>r.y a - - 1 085 0 7
pan.t.m 1 - - 5 587
Pam
p miLEM
p Unitrd Kingdo. A/
1
1
1
-
2
5
-
9
l
-
-
S
5
3
-
6
-
4
4 1
- 1
l
-
1
l 1
- 5 4CO
U 5 723
5 321
Us 632
fl Un1t.d Sat..
l
dd 60
ll V e w z w l . 1 1 9 20672
Tot.1 f = 19 S t t l t u ll3 24 293 5l 1l l 0 63 7 203 6 3
PN.T,CIIEDULFD I K P I R ~ 1 4 T l O W ~

Indlr
L Thihlrl
1
1
-
-
-
-
-
-
1
1
-
-
-
-
1
1 -
- l2a 347
6 United Kingdo. 1 6 - 3 664 10 707

2 1 -
-
- 3
- -
Tot.1 far 5 S h t o a 9 2 - - 33 3 1 16

@!Cl(CIUIm 1PeS-
Argon- 1 1 - - 1 - --
Au.ttmli. 9 1 - -
-
1
a
1
- 4 -
BOU*
nr..i1
Colwhi.
$ Price
1
1
2
6
1
1
1
2
-
4
8
- -
-
- l
3
1
l
-
--
1 - -
1 - 1 a0 732
i , i
a,
Iran I - - -
-
9
- -- -
-
-
i
4
:
-
-
. p ".I Z.l.rd
nio".p,o
1
2
0
1 1
-
- -
1 1 P
-
- -
- -
4 1
1 -
3
70 #1 9 2%
L nornr 1 1 - - 1 - 949 628
# PNlipploem
1Suedan
Woa of h t h Kri-
l
2
6
6
-
1
-
-
-
- 1
-
-
-
1
4
-
-
15 395
1wy
18m
# United Uagdo. 6 1 - l l l 1 1 3 - 18 703 18 m

d
UNWl
Vencswla
16
1
2
4
-
2
27
-
6
205
- .
-
9
2 -
36

T o b l Im 21 S t r t e b 8q 20 b7 3 237 39 6 63 1 -
~ 4 l V L H U EOPIrATL(UB

~rs.11 I - - - - - a -
Colclbh 1 1 -
--
-
--
2 -
- -
ha.
# lara.1
9
1
1
I
-
1
-
-
-
.
3
-
-- -- - 1
2

-
28
3%
u ory
474
19nd.n
@
J.pm
United NWo.
1
1
4
1
-
1
1
-
-
-
-
-
- 2
- 1
3 5
.
-
l45
19 075
103
a o 537
(4) (4 (-1 ( 1 5 4 (4 (15ul) (15050)
ll ) ) 1 2 5 2 . 91 no E/
1 0 ~KO1 m stab. 11 6 4 - 4 8 2 3 5 2 -

=I S
- d Pt.1 U r T n n . p o r t iioportiw T o n 0 t1l.d bl o w t r i o . ir.llo.t.d with $.
A l l o t h u oovntrr &t4 o o l l e o t d ha outaid. .ouro.

I '
~ Pta n f w to a i r u r n s r b d e t m d i n t h e V n i t d Kin+
I.tlmtd.
I
U n i t d Ki- d.t. o Q . P t a i r n 6 . t . Lor &r
hta t o r dl wh*hld U.8. lad Al.mka d r l l m . .
of
md it. d.poMlsmlea, Pt.imoq,l.t*
U n ( l . rod huur. flown.
far nub.? of l.r.ll~~(.
Uld h s flwn.

L/ 1mlud.n m wn-.oh.duld .ad ww-nvwtu* d a t a tor a l r l i r u . other thu, U r rtamm.

ti Data 1ncolpl.t. Tor mmbr of l a n d h s m d how* rlwn.
Hon-msMld i n t m ~ r n t i o n ol p n t l o n e a n owblrud with mn-aoh.duld domsatio operrtiona.
e/ 0hrt.r.d .iro&.
H a r e flown p r i n t * operator. ~t avtdlrrole
Pt.f a d l sohaduld U.9. ard U s k a a i t l l m s a* r.ll mr lrregrlur a i r aarriora.
U r INID* a.
I -- ---
f N I L H N A r l U N A L ClVlL AVIATION OHOANIZA VlON b l A1 IS! ICY hEL.!lON ( U c ~ a ~ n b e1956)
r
 FCRM G

INTERNATIONAL CIVLL AVIATION ORGANIZATlON

-
AIR TRANSPORT REPORTING FORM

UXIKIRY ............... AIRCRAFT ACCIDENTS WAR m m . . . ..........

NlmbrofA- p=-S~ Info?. C m h)y, ahaIn)prcd
Number of Ikum
Nmofopr- T y p of Opcntlom Flown
T d P d F d scdol. F Mad F d Sebom
1
N (2, C3 (4) (5) (b) 0) (8) 19) (10) (11) Cfs) (14)
.sc&d&d-
k h s d u L d ~ e
Nan-SckauJd h k m a t b d I
Ng-sckdUMODmCPjc
Noo-k.mw *ho
TdOpndcra . _ _ - - - - -

sckddd-tIoMJ
ScbednLdDome
Non-sckdald b t c m a b d
Nm-Scheduled lhmeslk
Ng-RevamrFlightl

T d MQI. - - - - - -
SchcdulalhltaMtImJ
ScbcrLdDomePLc
NOn-Schtdntd-oal
N o P S c h c w Domattc
h-I(rreQIe *htl

-
Total ~~ - - - - -
kbafnLdwtimul
SchcdukdDomwtic I
N.m---tiWnl
Nm-LWnlrd
N a p R c s c ~ ~

,
T e d *ran06 - - - - - - -
-
k a l k
I rqtrl--wfbc
[ :=Ld*---&-a@ ..................
D(X 73.57 - =A1529 - 1/58 The rttedoa of ICAO be h u m 1~ any lmrvoidahle &viation baa thc k a n e h a .
2 30 ICAO C i r c u l a r 5 0 - A ~ / 4 5

INSTRUCTIONS

Reporting Period: This f o r m i s to be filed annually by each State in respect of a i r c r a f t

accidents of operators, registered in the country, which a r e engaged in public a i r
transport.

Filing Date: This f o r m should be filed not l a t e r than 2 months a f t e r the end of the year
to which i t r e f e r s .

Notes; 1) Data f o r individual operators a r e required only in respect of those operators

whose a i r c r a f t were involved in an accident - r e g a r d l e s s of where the
accident took place.
2) The total number of hours flown by all operators (whether involved in
accidents o r not) should a l s o be inserted in the space provided. The f o r m
should be filed giving this information even i f t h e r e a r e no accidents t o report.

A i r c r a f t Accident means an occurrence associated with the operation of an a i r c r a f t

which takes place between the time any person boards the a i r c r a f t with the intention of
flight until such time a s all such persons have disembarked, in which:

a) any person suffers death o r serious injury a s a result of being in o r upon the
a i r c r a f t o r by direct contact with the a i r c r a f t o r anything attached thereto, o r
b) the a i r c r a f t received substantial damage (Annex 13).

An accident resulting in only minor injuries o r damages need not be reported.

A collision between two o r m o r e a i r c r a f t should be reported separately f o r
each ope r a t o r involved, and additional details should be provided under
'Remarks1

Type of Ope ration:

a) 'Scheduled International1, 'Scheduled Domestic1, 'Non-Scheduled International!
and 'Non-Scheduled Domestic8 operations relate to flights operated f o r the
purpose of carrying revenue load.
b) 'Non-Revenue Flights' relate to positioning flights, t e s t flights, training
flights, etc. .
c ) Data should be reported in columns 3 to 12 opposite the type of operation in
which the a i r c r a f t was engaged a t the time of the accident.
d) Data should be reported in columns 13 and 14 relating to the total activities
of the operator during the y e a r , subdivided into the types of operation indi-
cated.

P a s s e n g e r Injury: Include the total number of passengers involved, both revenue and
non-revenue .
Crew Injury: Include hostesses, stewards and supernumerary crew in addition t o flight
crew.

Others Injured: Include a l l persons injured other than those aboard the a i r c r a f t .

Number of Landings: If the number of landings cannot be ascertained without difficulty

a n estimate may be given and a note inserted under 'Remarks' indicating that the figure
i s an estimate.

Hours Flown: Report to n e a r e s t number of whole hours. Indicate under 'Remarks'

basis used -
such a s 'block-to-block1, 'wheels off-wheels on', e t c . .
 ICAO Circular 5 0 - ~ N / 4 5
PART I11
PILOTS SAFETY EXCHANGE BULLETINS
Wind Shear - A Two-Edged Sword
I1It's a r a r e day when there isn't a little
wind shear kicking around. If you have the
wind blowing one speed and direction here and
another speed o r direction a short distance away,
that's wind shear. A cold o r warm front i s a
good example, with the warm a i r moving inone
direction and the cold a i r below going in another.
"The strong wind that suddenly springs up
just before an afternoon thunderstorm i s anoth-
e r example. At one instant it is calm; the next
i t i s blowing and raining. The dividing line be-
tween the calm a i r and the wind i s the wind
shear line.
"A wind shear between ground and traffic
pattern altitude of 15 to 20 knots i s common,
and a shear of 30 to 40 knots is not uncommon
in some parts.
llSuppose you were coming down on final
a t 15 knots above stalling speed and you passed
through a wind shear line where the headwind
decreased by 15 knots? The result would be a
stall, and the only way to prevent it would be to
either sacrifice altitude for airspeed o r in-
crease airspeed by adding power. If you have
enough altitude, you can drop the nose and hit
the throttle, and then drag it on into the field
and make a landing. But if your altitude should
run out before the added power takes hold, you
land short. The opposite could happen, too.
You could pick up a 15-knot headwind ... and
fly way, way down the field before the plane
would give up and finally touch down.
"Wind shear also can be a problem on
take-off. Even with maximum take-off power,
a heavily loaded transport takes s e v e r a l sec-
onds to build up airspeed to, say, 25 knots above
stalling. If you were to run through a wind
shear line that decreased your airspeed by 20
knots just a s your wheels started up, you'd prob-
ably settle back down on the runway with a thud.
Where to Find Wind Shear
llWherever there i s a temperature inver-
sion you nearly always will have some wind
shear. Since inversions form almost every
231
clear night, late night and early morning hours
a r e a good time to be extra wary. Night-time
inversion caused by the Great Plains high i s
sometimes low enough to cause traffic pattern
wind shear anywhere from the Appalachians to
the Rockies, from Alaska to Texas. The effect
is more pronounced when there i s a cold high
pressure cell spread out over the plains and
pushing up against the Rockies. In that a r e a
you might find a westerly wind of a s much a s 40
knots, while a t the surface the wind would be
nearly calm.
Induces Undershoot
"Another wind shear situation exists where
there is a strong surface wind blowing. Moving
rapidly over trees, etc., the wind closest to the
ground i s slowed down so that from 25 to 50 feet
above the surface and on up the wind i s blowing
faster than it i s at the surface. This friction-
induced wind shear always tends to make you
land short.
"It is important to be able to recognize a
wind shear situation when you see it.
How to S ~ o Wind
t Shear
1. Look for an inversion below traffic
pattern altitude. Smoke rising in one direction
for a few hundred feet, then suddenly turning
and taking off in another direction above that, i s
a sure sign. Smoke from high stacks going in a
different direction than that from short ones. A
flat-topped haze o r smoke layer also indicates
an inversion. This i s usually the best way to
spot one of the night-time wind shear inversions.
"2. When the wind a t pattern altitude i s
obviously stronger than that reported by the tow-
e r , you have shear. Be on your guard.
"3. When the tower reports strong sur-
face winds! say, over 30 knots, you a r e apt to
have a significant amount of friction-induced
shear in the lower 25 to 50 feet. Be prepared.
"4. When you see a thunderstorm approach-
ing the field, watch out for wind shear. It's cer-
tain to be there.
How to Counteract Wind Shear
"Landing :
"1. Make your final approach longer and
flatter. (Be reasonable, of course, don't drag
i t in f o r m i l e s . ) This enables you to c a r r y
more rpm, making full thrust available to you
m o r e quickly, should you need it. Also, with
the lower rate of descent, you pass through the
shear line slower. You then have m o r e time to
adjust your speed to compensate for the changed
windspeed in the lower a i r m a s s , whether it is
causing a n over- o r an undershoot.
"2. When the tower reports strong s u r -
face winds, i n addition to your longer and flat-
t e r approach, plan to land a little long. With
the strong wind, you will be able to stop in
plenty of time even i f you touch down a few hun-
dred feet f r o m the approach end.
"3. When the surface wind i s strong and
gusty, allow yourself a little extra margin of
airspeed on the final.
Take -off:
"1. Get plenty of airspeed before you
pull up the gear. Accelerate to climb speed a s
rapidly a s possible.
"By following these simple rules, you
will practically eliminate the chances of your
landing too s h o r t o r too long, o r goofing a take-
off because of wind shear. n - (Adapted f r o m
"Change Without Notice!" USAF "Flying Safety,"
April, 1956.
Pilots Safety Exchange Bulletin 56- 106
dated 10 July 1956
Air Transport Division,
Flight Safety Foundation. Inc.
 ICAO Circular 5 0 - ~ N / 4 5
F L I C K E R VERTIGO
Recently the Flight Safety Foundation re-
ceived a letter concerning an experience in-
volving flicker vertigo. The contents of the let-
t e r and some additional information on the sub-
ject follow:
"Approaching for a landing a t a small mid-
west field, flying a Culver Cadet directly into a
setting western sun, during the latter p a r t of the
approach I very nearly passed out and felt a gen-
e r a l wave of nausea. I was able to land the a i r -
craft, but taxying further on down the runway I
still felt this impending sickness which ceased
when I finally turned away f r o m my westerly
heading.
"It has been only recently that I read a
book called THE LIVING BRAIN, by W. Grey
Walter, in which reference i s made to the fact
that a reaction s i m i l a r to epileptic seizure can
be induced in a perfectly normal subject by
means of imposing a flickering light on the sub-
ject. When the frequency i s critical, subjects
can react in various ways, f r o m feeling nausea,
to passing out, to actually having the beginnings
of an epileptic fit.
"The bright, short flashes a t frequencies
of 10 to 20 per second seemed to be the critical
range for most subjects.
"In a single-engine a i r c r a f t , approaching
a setting sun, a condition such a s this can be
reached when the throttle i s retarded and the
engine operating f r o m 300 to 600 rpm. I be-
lieve now that this was the condition that exist-
ed a t the time of my landing, and that the clin-
ical t e s t s conducted by Dr. Walter indicate the
remedy for such a situation would be to in-
c r e a s e the engine rpm. !*
Another Experience F r o m a Pilot Engineer
"During a recent flight in the B-26, a con-
dition was encountered in which vertigo could
be induced at will. Vertigo i s not really r a r e ,
but written reports on it s e e m to be sufficiently
uncommon that I thought the following first-hand
account might be of interest:
"Webster defines vertigo a s 'dizziness o r
swimming of the head'. In aeronautical c i r c l e s
the word usually means a l o s s of the sense of
the true vertical, a s well a s a turning sensation.
233
F u r t h e r m o r e , vertigo doesn't mean merely that
one does not know which way i s up; one feels
strongly that some wrong direction i s the proper
one. The feeling isn't vague. It i s a l m o s t over-
powering. Vertigo i s apparently affected by vi-
sion a s well a s the other cues to balance.
"A hood and instruments were installed
in the B-26 to allow the co-pllot to fly on instru-
ments. The hood was made of thin Masonite and
consisted of several pieces arranged a s a baffle.
so the pilot (safety pilot) viewed them edgewise
and could therefore s e e out, while the co-pilot
mewed them broadside and could not s e e out.
The piece n e a r e s t the co-pilot was about a foot
in front of his eyes, and ended on the right side
at the structure separating the back of the wind-
shield f r o m the front of the canopy. This piece
was not fastened down tightly. It could and did
vibrate with a high frequency (probably engine
frequency) and very small amplitude. F u r t h e r -
m o r e , i t dld not fit tightly against the s t r u c t u r e ,
and light could come in between the s t r u c t u r e
and the hood piece and shine on the hood.
Reflection produces Flicker
**Whenthe airplane was headed in a c e r -
tain direction relative to the sun, sunlight did
come past the windshield s t r u c t u r e and shone on
the hood. If the rays of sunlight were nearly
parallel to the plane of the hood piece, the vibra-
tion of the hood piece made a flickering pattern
of light a c r o s s the brown unpainted Masonlte.
As soon a s the flickering appeared i t caused an
immediate attack of vertigo. There was no ap-
preciable build-up time required, a s i s neces-
s a r y for a i r sickness for example. The vertigo
could be turned on and off a t wlll by h o l d ~ n gthe
hood piece tight against the windshield s t r u c t u r e ,
which both stopped the vibration and shut off the
light. The independent effects of light and vibra-
tion were not investigated. I believe, but do not
guarantee this recollection, that the vertigo per-
sisted about one second after the flickering light
was shut off, and that the sense of equilibrium
remained upset until i t came back and settled
down, almost with a click, a t the end of the
second.
"I thought a t f i r s t that the hood had slipped
and was allowing me to see out and s e e a hill-
side rushlng by. The viWration and the light on
the brown Masonite looked like a hillside covered
2 34 ICAO Circular 5 0 - ~ ~ / 4 5
with t r e e s which had not yet gotten any leaves.
This impression was all the stronger because
i t was known to be a possible one, since the a i r -
plane was known to be flying low in hilly country.
Effects
"As soon a s the vertigo'started I felt very
strongly that we were in a steep diving t u r n to
the right. After a s h o r t period (perhaps 1/2 to
1 second) of astonishment a t such a sudden
change in the attitude of an airplane which had
been giving me no trouble, I recognized the ef-
fect a s vertigo and concentrated on the instru-
ments. The instruments did not look real, and
appeared to be floating in space, but they could
be read all right. However, a lot of will power
was required to believe them, and a lot of men-
tal effort was required to f o r c e myself to me-
chanically scan and interpret the instruments
by direct intellectual effort instead of by habit.
The artificial horizon I was using had about a
70 bank angle e r r o r , and I couldn't remember
which direction the e r r o r was in. I therefore
looked a c r o s s to the pilot's horizon instead of
the small electric instrument. The vertigo
stopped but it was found by t r i a l that it stopped
because turning my head sufficiently to s e e the
other instruments brought i t well off to one side.
A little investigation showed that it was not pos-
sible to see the ground through the crack between
the hood and the windshield structure. The im-
pression of ground rushing by remained strong,
however.
Corrective Measures
"When the source of the trouble was found,
I spent a little time turning the vertigo on and
off to study the effect. If we wanted to fly on
.the heading which put the sun in the proper posi-
tion to make the light shine nearly parallel to
the hood, I had to hold the hood tight against
the windshield structure. W e solved the prob-
lem in practice by flying in some other direc-
tion. A 150 change in heading would suffice. I t
was not just a question of sunlight on the hood.
That occurred anytime the sun was beside o r
behind the airplane. The sun had to shine
through the crack nearly parallel to the hood to
allow the vibration of the hood to modulate the
light. I considered the possibility that the light
was shining through the propeller disk and was
being modulated by the propeller blades, but
the angle was wrong, making this impossible.
Powerful impression
"The most remarkable thing about this ex-
perience was the strength of the erroneous
impression a s to the airplane's attitude. It took
r e a l will power to toss out that impression and
concentrate on the instruments. I have about 320
hours of instrument time and have given consider-
able instrument instruction, and I a m familiar
with the m o r e common f o r m s of l o s s of equilib-
rium. F o r example, there i s the slight loss of
orientation during recovery f r o m a steep t u r n o n
instruments, when one thinks the airplane i s
turning the other way and the nose i s going
down. There a r e also the 'leans1, when the pilot
gradually begins to think a wing i s down. He con-
tinues to fly by instruments, but gradually leans
h i s body to one side, and may actually reach
quite ludicrous angles if the cockpit i s big enough.
He suddenly realizes he i s leaning and 'recovers'
with a s t a r t , feeling rather foolish, A third ex-
ample, which occurs rather often, i s one in
which the pilot has a rather vague feeling that
the airplane i s doing something foolish, but the
feeling i s not strong enough to interfere serious-
ly with his flying. The feeling may p e r s i s t for
a long time, such a s an hour.
"There was no possibility of shaking the
head o r blinking the eyes to break up the false
impression in the incident I have been describing,
because the source of stimulus was still there
and s t a r t e d the vertigo going again immediately.
"As pointed out in the beginning, vertigo
i s not r a r e , but this was far the strongest case
I have experienced, o r even heard of. F u r t h e r -
m o r e , the ability to turn the vertigo on and off
a s easily a s with a switch was interesting. I f
SCIENTIFIC COMMENT
"Many thanks for your letter about the ef-
fects of flicker in ground lighting s y s t e m s . I
a m interested to h e a r that the disagreeable ef-
fects of flicker have been noted and guarded
against in these systems, but I think those con-
cerned should be warned that a frequency of 5 to
8 flashes p e r second in what they call the 'flicker1
range can also produce unpleasant effects in c e r -
tain susceptible individuals, particularly during
states of mind such a s fatigue and frustration.
I would recommend very strongly therefore that
rather extensive t e s t s should be made of a large
population of young people during the appropriate
psychological conditions of annoyance and weari-
n e s s before this frequency i s standardized for
conditions in which pilots will'be predisposed. The
subject has been very extensively Investigated in
our laboratory and elsewhere and results a r e in
fact used for diagnostic purposes in the clinic.
"You may be interested to know that dur-
ing the war, the German searchlight system was
 ICAO Circular 5 0 - ~ ~ / 4 5
arranged to flicker for various reasons and al-
though the precise purpose of this was never
discovered by our agents, it was found that the
main effect was to irritate the pilots. There is
a detailed report on this subject by our National
Physical Laboratory from a s far back a s 1940.
They found that the worst frequency for search-
light flicker was between 4 and 12 c/s. This is
described a s having an 'almost sickening effect
and the observer has to exercise a certain ef-
fort of will to continue looking."
"This subject has come up for discussion
many times in aviation medicine and, of course,
i t i s not too much of a problem in commercial
aviation with most of the aircraft so arranged
that the pilot i s sitting in front of his propellers.
However, I think i t i s interesting that in single
engine aircraft where the pilot i s looking
235
through the propeller the possibility does exist
of some stroboscopic effect.
"I learned of this phenomenon several
years ago when I attended some lectures in
brain wave technique at Harvard University.
We have had in this airline some inquiries of
the effect on passenger personnel when sitting
in the cabin and the propellers a r e cutting sun-
light to give a flashing effect on passengers
seated at window seats."
(Pilot Safety Exchange Bulletin 55-1 10
dated 30 November 1955)
Air Transport Division
Flight Safety Foundation, Inc.
THIS PAGE INTENTIONALLY LEFT BLANK
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 237

PART IV

L i s t of Laws and Regulations of the Contracting S t a t e s containing

p r o v i s i o n s relating to "Aircraft Accident Investigationt1
(Replacing l i s t s i n Digests Nos. 5 and 6)

ARGENTINA

1952 Oct. 9 -
Resoluci6n N h . 100 (S.A.C. ) N o r m a s p a r a la investigaci6n d e
accidentes d e aviacidn civil y d i r e c t i v a s g e n e r a l e s p a r a l a investigaci6n.
Arnpliada e l 8 d e e n e r o de 1954.

1954 e n e r o 12 -
D e c r e t o NGm. 299 Creaci6n d e l a Junta de Investigaciones d e Acci-
dentes d e Aviaci6n y competencia d e l a S u b s e c r e t a r t de Aviaci6n Civil
y Comando en Jefe d e la F u e r z a A 6 r e a Argentina e n l a Investigaci6n
d e Accidentes civiles y m i l i t a r e s respectivamente.
julio 15 -
L e y NGm. 14. 307 Cddigo Aeronautico d e l a Nacibn: Tftulo XVIII. -
Disposiciones v a r i a s (Art. 208).

AUSTRALIA

1947Aug. 6 T h e A i r Navigation Regulations, S. R. No. 112/1947, a s a m e n d e d up to

-
1 March, 1956: P a r t XVI. Accident Inquiry (Reg. 270-297).

BOLIVIA

1949 junio 18 Procedimiento p a r a e l i n f o r m e d e a c c i d e n t e s (Boletrn Oficial NGm. 2 -

Sec. OP-100).

1950 m a r z o R e g l a s G e n e r a l e s d e O p e r a c i o n e s (Provisional): Accidentes d e Aeronaves,

(02.46-02.52).

BRAZIL

1951 July 24 P o r t a r i a No. 280 - Recommendations relating to a i r c r a f t accident

investigations.

BURMA

1934 T h e Union of B u r m a A i r c r a f t Act, 1934 (XXII of 1934): Section 7. -

Power of the P r e s i d e n t of the Union to make r u l e s f o r investigation
of accidents.

The Union of B u r m a A i r c r a f t Rules, L937, as amended up to 1 3 March,

-
1956: P a r t X. Investigation of Accidents.

1949 August Notice to A i r m e n No. 5/1949 - A i r c r a f t Accident and Incident Investiga-

tions.
238 ICAO C i r c u l a r 5 0 - ~ N / 4 5

CANADA

1954 Nov. 23 T h e A i r Regulations, O r d e r i n Council P . C . 1954-1821, a s a m e n d e d up

t o 2 F e b r u a r y 1956: P a r t VIII. - Div. 111. - Accidents and B o a r d s of
Inquiry.

CEYLON

1950 M a r c h 29 A i r Navigation Act, No. 15/1950: P a r t I. - Section 1 2 - P o w e r t o

provide f o r investigation i n t o accidents.

1955 May 4 Civil Air Navigation Regulations: Chap. XVI.

(Reg. 260-271).
- Accident h q u i r y
CHINA (TAIWAN)

1953 Oct. 31 Civil A i r Regulations No. 102 - Accident R e p o r t i ~ gand Investigation.

COLOMBIA

1948 m a r z o Manual de Reglamentos ejecutados p o r e l D e c r e t o N h . 969 d e 14/3/47

y e l D e c r e t o N b . 2669 d e 6/8/47: P a r t e IV - 40.13.0: Accidentes.

CUBA

1954 dic. 22 Ley-Decreto NGm. 1863 p o r l a c u a l s e c r e a l a Comisi6n d e AeronAutica

Civil, Organizaci6n y F a c u l t a d e s : A r t . 11, 17) Investigaci6n de
Accidentes.

CZECHOSLOVAKIA

1947 D e c r e e of Ministry of I n t e r i o r o n accident investigation, No, 1600/47.

DENMARK

1920 Sept. 11 Air Navigation Regulations: P a r a . 22 - Notifications in c a s e of c e r t a i n

a i r c r a f t accidents,

ECUADOR

1954 julio 8 Reglamento de Aerontiutica Civildel E c u a d o r , N t m . 7:

TItulo 11, P a r t e 8. - Investigaci6n y e n c u e s t a d e a c c i d e n t e s de aviaci6n.

EGYPT

1941 May 5 D e c r e e : A i r Navigation Regulations - Article 10.

E L SALVADOR

1955 dic. 22 -
D e c r e t o Nbm. 2011 Ley de Aerondutica Civil:
Cap.. XV. - De la Investigaci6n de Accidentes A 6 r e o s (Art. 173-187).
 ICAO C i r c u l a r 5 0 - ~ N / 4 5 239

FRANCE

1937 a v r i l 21 D k c r e t relatif B l a dkclaration d e s akcidents dlaviation.

1953 jan. 3 Instruction m i n i s t k r i e l l e r e l a t i v e ?i l a coordination d e ltInformation

judiciaire e t de ltenquCte technique e t a d m i n i s t r a t i v e e n c a s d t a c c i d e n t
s u r v e n u ?i un akronef f r a n q a i s ou & r a n g e r s u r l e t e r r i t o i r e de l a
Mktropole e t l e s t e r r i t o i r e s d t o u t r e - m e r .

dkc. 11 Instruction du S e c r k t a r i a t d f E t a t a u x T r a v a w P u b l i c s e t llAviation

Civile no 200 ICAC/SA, concernant l e s dispositions A p r e n d r e e n c a s
d ' i r r k g u l a r i t k dlincident ou d t a c c i d e n t d'aviation.

GUATEMALA

1948 o c t , 28 D e c r e t o NGm. 563 - L e y de Aviaci6n Civil: Capitulo X. - De 10s

s i n i e s t r o s aeronduticos (Art. 116-121).

HONDURAS

1950 m a r z o 14 D e c r e t o NGm. 121 - L e y de Aerondutica: Cap. IV - Sec. C u a r t a -

Accidentes y E m e r g e n c i a s ( A r t . 70-88).

INDIA

1934 Aug. 19 The Indian A i r c r a f t Act, 1934, ( c o r r e c t e d up t o 1 November 1950):

Section 7. - P o w e r s of C e n t r a l Government t o m a k e r u l e s f o r Investiga-
tion of Accidents.

1937 M a r c h 23 T h e Indian A i r c r a f t Rules, 1937, a s c o r r e c t e d up to 10 July, 1956:

P a r t X. - Investigation of Accidents (Art. 68-77A).

IRAQ

1939 Aug. 6 Air Navigation Law No. 41: A r t i c l e 5 (h).

IRELAND

T h e A i r Navigation (Investigation of Accidents) Regulations, S . R. and 0

No. 21, a s amended by A i r Navigation (Amendment) Regulations, S.R.
and 0. No. 288, 3 August 1943.

T h e A i r Navigation and T r a n s p o r t Act, No. 40: P a r t VII - Section 60 -

Investigation of Accidents. T h i s Act h a s been amended by Amendment
A c t s No. 10, 1942; No. 23, 1946 and No. 4, 1950.

ITALY

1925 Jan. 11 D e c r e e Law No. 356 - Rules f o r A i r Navigation: Chapter VII.

1942 A p r i l 21 T h e Navigation Code, approved by Royal D e c r e e No. 327 of 30 M a r c h ,

1942: Second P a r t . - A i r Navigation - Investigation of Accidents
( A r t . 826-833).
240 ICAO C i r c u l a r 5 0 - ~ N / 4 5

JAPAN

1952 July 15 Civil Aeronautics Law No. 231, a s amended up to i April, 1954:
Chap. 9 - A r t i c l e 132. - Investigation of Accidents.

LEBANON

1949 J a n , 11 Aviation Law: Chap. 111 - Sub-chapter 2. - Landing of A i r c r a f t

(Art. 39).

MEXICO

1949 dic. 27 L e y de Aviaci6n ( L i b r o IV de l a Ley de Vias G e n e r a l e s de Comunicacidn):

Cap. XIV. - De 10s accidentes y de l a bGsqueda y salvamento (Art. 358-
361).
1950 Oct. 18 Reglamento p a r a BGsqueda y Salvamento e Investigaci6n de Accidentes
A e r e o s ( e n vigor a p a r t i r d e l 1 de e n e r o d e 1951).

1936 Sept. 10 -
Law Investigation of Accidents to civil a i r c r a f t , amended by Law of
31 D e c e m b e r , 1937, ( c o n c e r n s i n t e r a l i a the g r e a t e r p a r t of the provi-
s i o n s of Annex 13).

1936 Sept. 22 Royal D e c r e e : Application of p a r a s . 8 and 9 of A r t i c l e 1 and of p a r a . 5

of A r t i c l e 32 of the Law dated 10 September, 1936.

Sept. 22 Royal Decree: Application of p a r a . 2 of A r t i c l e 6 of the Law of

10 September, 1936.

NEW ZEALAND

1948 Aug. 26 T h e Civil Aviation Act, 1948: A r t . 8. - P o w e r to provide f o r investiga-

tion of accidents.

1953 Nov. 11 T h e Air Navigation Regulations, S e r i a l No. 152/53, ( m a d e i n accordance

with ICAO Annex 13).

NORWAY

1923 Dec. 7 Civil Aeronautics Act, a s amended up to 17 July, 1953: C h a p t e r XI.

Royal Resolution - Regulations on aviation enacted by the Department

of Defence, 15 October 1932, i n accordance with the Civil Aeronautics
Act of 7 D e c e m b e r , 1923, and the Royal Resolution of 22 A p r i l 1932,
a s amended up to 1950: VIII. - A i r c r a f t Accidents.

PAKISTAN

1934 Aug. 19 T h e A i r c r a f t Act, No. XXII of 1934 ( c o r r e c t e d up to 26 October 1950):

P a r a . 7. - P o w e r of C e n t r a l Government t o make r u l e s f o r investiga-
tion of accidents.
 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5 24 1

PAKISTAN (Cont'd)

1937 M a r c h 2 3 T h e A i r c r a f t R u l e s , ( c o r r e c t e d up to 14 A p r i l 1953): P a r t X. -
Investigation of a c c i d e n t s .

PHILIPPINES

1946 May 9 C i v i l Aviation Regulations: Chap. XVI. - A i r c r a f t A c c i d e n t Regulations.

1952 J u n e 20 T h e Civil A e r o n a u t i c s Act of the P h i l i p p i n e s , NO. 776: Chap. V. -
Section 32 - P o w e r and D u t i e s of the A d m i n i s t r a t o r : (1 1 ) Investigation
of Accidents.

PORTUGAL

1931 Oct. 25 D e c r e e No. 20.062 - A i r Navigation Regulations: C h a p t e r VIII.

SPAIN

1948 m a r z o 1 2 D e c r e t o del M i n i s t e r i o d e l A i r e s o b r e i n v e s t i g a c i 6 n de a c c i d e n t e s y
auxilio d e a e r o n a v e s .

SWEDEN

1928 A p r i l 20 Royal P r o c l a m a t i o n No. 8 5 r e g a r d i n g Application of t h e D e c r e e of

26 May 1922, (No. 383) on A i r Navigation ( a m e n d e d u p t o 1953 Code
of Law 42: 1953): P a r a . 28. - Notification of a i r c r a f t a c c i d e n t s .
-
-
Civil Aviation Regulations ( B C L ) O p e r a t i o n a l R e g u l a t i o n s (D):
A i r c r a f t Accident Inquiry - ICAO Annex 13.

SWITZERLAND

1,948 d6c. 21 L o i f k d 6 r a l e s u r l a navigation a 6 r i e n n e ( e n t r e e e n v i g u e u r l e 1 5 juin

1950): A r t i c l e s 22-26.

1950 juin 5 Rkglement d'ex6cution de l a loi s u r la navigation a 6 r i e n n e : XIV. -

Accidents d 1 a 6 r o n e f s ( A r t i c l e s 129-137).

UNION O F SOUTH AFRICA

1923 M a y 21 Aviation Act No. 16: A r t i c l e 10. - Investigation of Accidents.

1949 Dec. 30 T h e A i r Navigation Regulations, NO. 2762, 1950, a s a m e n d e d u p t o
1 7 S e p t e m b e r , 1954: C h a p t e r 29. - Investigation of A c c i d e n t s
(Regulations 29.1 -
29.7).

UNITED KINGDOM

1949 Nov. 24 T h e Civil Aviation Act, 1949 (12 and 1 3 Geo. 6. Ch. 67):
P a r t I1 - Section 10 - Investigation of Accidents.

1951 Sept. 5 T h e Civil Aviation (Investigation of A c c i d e n t s ) Regulations, S.I. No. 1653.

C a m e into o p e r a t i o n o n 1 O c t o b e r , 1951.
242 ICAO C i r c u l a r 50-AN/G

UNITED KINGDOM (Contld)

1954 June 24 The Air Navigation O r d e r , S.I. No. 829, a s amended up to 3 August
1956: P a r t VI. - Article 70 - Application of accident regulations to
a i r c r a f t belonging to o r employed in the s e r v i c e of H e r Majesty.

UNITED KINGDOM COLONIES

1949 Oct. 28 Article 69 of the Colonial Air Navigation O r d e r s , 1949 to 1954, and
Section 10 of the Civil Aviation Act, 1949, apply fihe l a t t e r by virtue
of the Colonial Civil Aviatlon (Application of ~ c t O) r d e r , 1952, ( a s
a m e n d e d 2 to the undermentioned Colonies:

Aden (Colony p r o t e c t o r a t e )
Bahamas
Barbados
Basutoland
Bechuanaland P r o t e c t o r a t e
Bermuda
B r i t i s h Guiana
B r i t i s h Honduras
B r i t i s h Solomon Islands P r o t e c t o r a t e
Cyprus
Falkland Islands and Dependencies
Fiji
Gambia (Colony and P r o t e c t o r a t e )
Gibraltar
Gilbert and Ellice Islands Colony
Gold Coast - ( a ) Colony
(b) Ashanti
(c) Northern T e r r i t o r i e s
(d) Togoland under United Kingdom t r u s t e e s h i p
Hong Kong
Jamaica (including T u r k s and Caicos Islands and the Cayman
Islands)
Kenya (Colony and p r o t e c t o r a t e )
Leeward Islands - Antigua
Montserrat
St. Christopher and Nevis
Virgin Islands
Malta
Mauritius
Nigeria - ( a ) Colony
(b) P r o t e c t o r a t e
( c ) Cameroons under United Kingdom t r u s t e e s h i p
North Borneo
St. Helena and Ascension
Sarawak
Seychelles
S i e r r a Leone (Colony and P r o t e c t o r a t e )
Singapore
Somaliland P r o t e c t o r a t e
Swaziland
Tanganyika
Trinidad and Tobago
Uganda P r o t e c t o r a t e
Windward Islands - Dominica
Grenada
St. Lucia
St. Vincent
Zanzibar P r o t e c t o r a t e .
 ICAO C i r c u l a r 50-AN/45 243

UNITED KINGDOM COLONIES (Cont'd)

-
ADEN

1954 T h e Civil Aviation (Investigation of A c c i d e n t s ) Regulations (G. N. 125/54).

BAHAMAS

1952 Aug. 1 A i r Navigation (Investigation of Accidents) Regulations.

BARBADOS

1952 A p r i l 29 A i r Navigation (Investigation of Accidents) Regulations.

BERMUDA

1948 Dec. 18 A i r Navigation (Investigation of Accidents) Regulations.

BRITISH GUIANA

1952 Aug. 18 A i r Navigation (Investigation of ~ c c i d e n t s Regulations,

) NO. 19/1952.

BRITISH HONDURAS

1953 Dec. 19 A i r Navigation (Investigation of Accidents) Regulations, 1953 (S.I. 1/54).

CYPRUS

1952 Nov. 17 C i v i l Aviation (Investigation of Accidents) Regulations (G. N. 51 7/1952).

-
FIJI

1952 May 1 Civil Aviation (Investigation of Accidents) Regulations ( L . N. 90/52).

GAMBIA

1937 May 1, A i r Navigation (Investigation of Accidents) Regulations, No. 8 and

Nov. 25 No. 1 7 of 1937.

GIBRALTAR

1952 J a n . 3 A i r Navigation (Investigation of Accidents) Regulations, 1952.

COLD COAST

1937 F e b . 17 A i r c r a f t ( ~ c c i d e n t Regulations,
) NO. 5/1937.

HONG KONG

1951 A i r Navigation (Investigation of Accidents) Regulations (G. N. 228/51).

JAMAICA

1953 Mar.ch 24 A i r Navigation (Investigation of ~ c c i d e n t s )Regulations (G. N. 37/53).

LEEWARD ISLANDS

1952 J u l y 31 Civil Aviation (Investigation of A c c i d e n t s ) Regulations (S. R. 0. 18/52).

244 ICAO C i r c u l a r 5 0 - ~ ~ / 4 5

UNITED KINGDOM COLONIES (Contld)

MALAYA (FEDERATION OF)

1953 Nov. 1 A i r Navigation (Investigation of A c c i d e n t s ) Regulations (L.N. 584/53).

MALTA

1952 Sept. 2 C i v i l Aviation (Investigation of ~ c c i d e n t s Regulations.

)

MAURITIUS

1952 Sept. 4 C i v i l Aviation (Investigation of A c c i d e n t s ) R e g u l a t i o n s (G. N. 200/52),

NIGERIA

1953 A p r i l 28 Civil Aviation (Investigation of ~ c c i d e n t s Regulations

) (No. 15/1953).

NORTHBORNEOANDLABUAN

1950 Jan. 6 A i r Navigation ( ~ n v e s t i g a t i o nof Accidents) Regulations (S. 8/50).

ST. LUCIA

1948 Nov. 27 A i r Navigation (Investigation of Accidents) Regulations (S. R.O. No. 40/48).

ST. VINCENT

1953 Jan. 8 A i r Navigation (Investigation of Accidents) Regulations (S. R. 0. NO. 6/53).

SARAWAK

1953 T h e A i r Navigation (Investigation of A c c i d e n t s ) Regulations (G.N. S 6/54).

SIERRA LEONE

195 3 Dec. 30 C i v i l Aviation (Investigation of Accidents) Regulations (P. N. 114/53).

SINGAPORE

1953 Oct. 1 Civil Aviation (Investigation of A c c i d e n t s ) Regulations (G. N. 301/53).

SOMALILAND

195 1 Nov. 7 C i v i l Aviation (Investigation of A c c i d e n t s ) Regulations (G. N. 48/195 1).

TRINIDAD and TOBAGO

1954 Nov. 23 A i r Navigation (Investigation of Accidents) Regulations (G. N. 205/54),

ZANZIBAR

1937 Sept. 4 A i r Navigation (Investigation of Accidents) Regulations (q.N. 41/1937).

FEDERATION O F RHODESIA AND NYASALAND

SOUTHERN RHODESIA

1952 Jan. 25 A i r Navigation Regulations, a s a m e n d e d up to 4 D e c e m b e r , 1953:

P a r t 18. - Investigation of Accidents.
 ICAO Circular 5 0 - ~ ~ / 4 5 24 5

UNITED STATES OF AMERICA

1938 Civil Aeronautics Act - Title VII (Air Safety).

1949 May 1 Civil Air RegulaUons - P a r t 62 - Notification and reporting of a i r c r a f t
accidents and overdue a i r c r a f t , ( a s issued effective May 1, 1949,
14 F. R. 1516; revised effective F e b r u a r y 11, 1954, 19 F.R. 891).

1950 Sept. 15 -
Economic Regulations P a r t 303 - Rules of practice i n a i r c r a f t accident
investigation information.

Sept. 15
investigation information.
-
Economic Regulations P a r t 311 - Disclosure of a i r c r a f t accident

1951 May 14 -
Civil Aeronautics Board Organizational Regulations Description -
of Functions: Course and method by which functions a r e channeled -
-
Scope and contents of documents Hearings concerning accidents
involving aircraft.

Title 22 - Foreign Relations -

P a r t 134 - Civil Aviation; Aircraft Accidents
(issued in Department Regulations 108.164, effective October 1, 1952,
17 F.R. 8207).

-
Public Notice PN 7 Administrator of Civil Aeronautics: Delegation of
certain accident investigation functions, ( a s issued, effective January 1,
1954, 18 F. R. 7499; reissued a s Public Notice PN 7 and amended,
April 13, 1954, 19 F , R . 2133).

Public Notice PN 8 - Delegations of final authority related to substantive

program m a t t e r s ( a s issued, effective October 27, 1954, 19 F.R. 7418):
Section 7. Director, Bureau of Safety Investigation.

Economic Regulations - P a r t 399 - Statements of General Policy,

a s issued, effective May 25, 1955: Section 399.26 -
Investigation of
Accidents involving foreign a i r c r a f t .

Public Notice PN 10 - Statement of Organization ( a s issued, effective

January 1, 1956, 21 F.R. 3481): 1 . 3 Functions.

URUGUAY

1955 feb. 2 Decreto N h . 23.826 - Reglamento p a r a l a Investigaci6n de Accidentes

de Aviaci6n de C a r i c t e r Civil.

VENEZUELA

1955 a b r i l 1 Ley de Aviaci6n Civil:

Cap. X.- De 10s accidentes y de l a bGsqueda y rescate.

- END -
 ICAO TECHNICAL PUBLICATIONS
The following summary gives the statu~, and also
describes in general ternis the contenfs o f the various
series of technical publications issued by the Inter-
nafional Civil Aviation Organization. It does not in-
clude specialized publications that do not fall specif-
ically within one of the series, such as the ICAO
Aeronautical Chart Catalogue or the Meteorological
Tables for International Air Navigation.
I N T E R N A T I O N A L S T A N D A R D S A N D RECOM-
MENDED PRACTICES are adopted by the Council
in accordance with Articles 54, 37 and 90 of the Con-
vention on International Civil Aviation and are desig-
nated, for convenience, as Annexes to the Convention.
The uniform application by Contracting States of the
specifications comprised in the International Standards
is recognized as necessary for the safety or regularity
of international air navigation while the uniform appli-
cation of the specifications in the Recommended Prac-
tices is regarded as desirable in the interest of safety,
regularity or efficiency of international air navigation.
Knowledge of any differences between the national regu-
lations or practices of a State and those established by
an International Standard is essential to the safety or
regularity of international air navigation. In the event
of non-compliance with an International Standard, a
State has, in fact, an obligation, under Article 38 of
the Convention, to notify the Council of any differences.
Knowledge of differences from Recommended Practices
may also be important for the safety of air navigation
and, although the Convention does not impose any obli-
gation with regard thereto, the Council has invited Con-
tracting States to notify such differences in addition to
those relating to International Standards.
PROCEDURES F O R A I R NAVIGATION SERV-
ICES (PANS) are approved by the Council for world-
wide application. They comprise, for the most part,
operating procedures regarded as not yet having at-
tained a suficient degree of maturity for adoption as
International Standards and Recommended Practices, as
well as material of a more permanent character which
is considered too detailed for incorporation in an Annex,
or is susceptible to frequent amendment, for which the
processes of the Convention would be too cumbersome.
As in the case of Recommended Practices, the Council
has invited Contracting States to notify any differences
between their national practices and the PANS when the
knowledge of such differences is important for the safety
of air navigation.
REGIONAL SUPPLEMENTARY PROCEDURES
(SUPPS) have a status similar to that of PANS in that
they are approved by the Council, but only for applica-
tion in the respective regions. They are prepared in
consolidated form, since certain of the procedures apply
to overlapping regions or are common to two o r more
regions.
The following publications are prepared by authority
of the Secrefary General in accordance with the prin-
ciples and policies approved by the Council.
ICAO FIELD M A N U A L S have no status in thern-
selves but derive their status from the International
Standards, Recommended Practices and PANS from which
they are compiled. They are prepared primarily for the
use of personnel engaged in operations in the field, as
a service to those Contracting States who do not find
it practicable, for various reasons, to prepare them for
their own use.
TECHNICAL M A N U A L S provide guidance and in-
formation in amplification of the International Standards,
Recommended Practices and PANS, the implementation
of which they are designed to facilitate.
A I R NAVIGATION P L A N documents detail re- ~
quirements for facilities and services for international
air navigation in the respective ICAO Air Navigation
Regions. They are prepared on the authority of the
Secretary General on the basis of recommendations of
regional air navigation meetings and of the Council action
thereon. The plans are amended periodically to reflect
changes in requirements and in the status of implanenta-
tion of the recommended facilities and services
ICAO CIRCULARS make available s p t c d i d mn-
formation of interest to Contracting States. This indudes
studies on technical subjects as well as texts of Rovisional
Acceptable Means of Compliance.
 EXTRACT FROM T H E CATALOGUE
ICAO SALABLE PUBLICATIONS
ANNEX
Annex 13 - Aircraft16accident
September 1951.
inquiry.
pp. . . . . . . . . . . . . . . . . . . . . $ 0 . 1 5

MANUAL
Manual of aircraft accident investigation.
(Doc 6 9 2 0 - ~ ~ / 8 5 5 ) 2nd
. edition, October 1951. . . . . . . . $0.75
ICAO CIRCULARS
18-AN/15 - Aircraft
June 1951.
Accident Digest No. 1.
116 pp. . . . . . . . . . . . . . . . . . . . . . . $ 0 . I5

24-AN/21 - Aircraft Accident Digest No. 2.

1952. 170 pp. . . . . . . . . . . . . . . . . . . . . . . . . . $ 0 . 8 5

31-AN/26 - Aircraft Accident Digest No. 3.

1952. 1 9 0 p p . . . . . . . . . . . . . . . . . . . . . . . . . . $ 1 . 0 0

38-AN/SS
1954.
- Aircraft
186pp. . . .Accident
. . . . .Digest
. . . .No.. .4.. . . . . . . . . . . $2.00

SO-AN/34
1955.
- Aircraft
185 pp.
Accident Digeat No. 5.
. . . . . . . . . . . . . . . . . . . . . . . . . $2.00
47-AN/42
1956.
- Aircraft
237 pp.
Accident Digest No. 6.
......................... $2.50

NB.-Cash remittance should accompany each order.

Catalogue sent free o n request.

PRICE: $2.50 (Cdn.) (Montreal)

Equivalents at date of publication:
50.00 bahts (Bangkok)
60.00 pesos (Buenos Aires)
L.E. 0.875 (Cairo)
49.50 soles (Lima)
17s. 6d. (London)
22s. 6d. (Melbourne)
Rs. 12-8-0 (New Delhi)
875 francs (Paris)